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School functioning of children with asthma

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Title:
School functioning of children with asthma a study of the elementary and middle school years
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Book
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English
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Johansen, Shannon Elizabeth
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University of South Florida
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Tampa, Fla.
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behavior
illness
longitudinal
achievement
education
Dissertations, Academic -- School Psychology -- Specialist -- USF   ( lcsh )
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government publication (state, provincial, terriorial, dependent)   ( marcgt )
bibliography   ( marcgt )
theses   ( marcgt )
non-fiction   ( marcgt )

Notes

Summary:
ABSTRACT: This study examined the school functioning of children with asthma compared to the school functioning of children without asthma over a 9-year time span. The present study was a secondary analysis of data from one large school district in a southeastern state. Information was gathered from multiple sources, including student records and parent and teacher surveys. Variables related to academics, behavior, and teacher perception were examined. A total of 646 participants were initially included in the study. These participants included 296 students identified as having asthma and 350 students identified as not having asthma. Participants were matched on gender, race, and socioeconomic status. Results of this study indicated significant differences for various years and subjects on a standardized achievement test. However, computed effect sizes were quite low, suggesting no practical difference between the groups. Additionally, rates of special education placement differed for the groups for one school year. All other years and variables indicated no significant differences between the groups. These findings suggest that educational experience of children with asthma may not differ significantly from that of their peers without asthma. However, future research should attempt to measure variables in different ways and possibly examine cases in a more qualitative manner.
Thesis:
Thesis (Ed.S.)--University of South Florida, 2004.
Bibliography:
Includes bibliographical references.
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System requirements: World Wide Web browser and PDF reader.
System Details:
Mode of access: World Wide Web.
Statement of Responsibility:
by Shannon Elizabeth Johansen.
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Title from PDF of title page.
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Document formatted into pages; contains 68 pages.

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University of South Florida
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aleph - 001469428
oclc - 55731828
notis - AJR1182
usfldc doi - E14-SFE0000329
usfldc handle - e14.329
System ID:
SFS0025024:00001


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ABSTRACT: This study examined the school functioning of children with asthma compared to the school functioning of children without asthma over a 9-year time span. The present study was a secondary analysis of data from one large school district in a southeastern state. Information was gathered from multiple sources, including student records and parent and teacher surveys. Variables related to academics, behavior, and teacher perception were examined. A total of 646 participants were initially included in the study. These participants included 296 students identified as having asthma and 350 students identified as not having asthma. Participants were matched on gender, race, and socioeconomic status. Results of this study indicated significant differences for various years and subjects on a standardized achievement test. However, computed effect sizes were quite low, suggesting no practical difference between the groups. Additionally, rates of special education placement differed for the groups for one school year. All other years and variables indicated no significant differences between the groups. These findings suggest that educational experience of children with asthma may not differ significantly from that of their peers without asthma. However, future research should attempt to measure variables in different ways and possibly examine cases in a more qualitative manner.
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School Functioning of Children with Asthma: A Study of the Elementary and Middle School Years by Shannon Elizabeth Johansen A thesis submitted in partial fulfillment of the requirements for the degree of Education Specialist Department of Psychological and Social Foundations College of Education University of South Florida Major Professor: Linda Raffaele-Mendez, Ph.D. Kathy Bradley-Klug, Ph.D. Robert Dedrick, Ph.D. Date of Approval: April 5, 2004 Keywords: achievement, longitudinal, education, behavior, illness Copyright 2004, Shannon Johansen

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ii Table of Contents List of Tables iv List of Figures vi Abstract vii Chapter One 1 Introduction 1 Rationale 2 Purpose 3 Chapter Two 5 Review of Literature 5 Prevalence and Definition 6 Symptoms and Treatment 8 Achievement 9 Special Education Placement 10 Retention 12 Placement in Drop-Out Prevention Programs 12 Absenteeism 13 Discipline 14 Teacher Perception 16 Summary 16 Chapter Three 19 Method 19 Participants 19 Variables 21 Procedure 24 Data Analysis 26 Chapter Four 28 Results 28 Chapter Five 49 Discussion 49 Limitations 51 Contributions to Literature 55

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iii References 57

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iv List of Tables Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Table 10 Table 11 Table 12 Table 13 Distribution of Original Sample by Gender, Race, and SES Distribution of Selected Participants by Gender, Race, and SES Means and Standard Deviations for Reading, Math, Language Arts, and Total Battery CTBS NCE Scores for the 1992-93 through 199798 School Years Means and Standard Deviations for Reading, Math, Language Arts, and Total Battery CTBS Scale Scores for the 1992-93 through 1997-98 School Years Effect Sizes for Statistically Significant Differences Among CTBS Scores Skewness and Kurtosis of CTBS NCE Scores Results of the 2 (Asthma) x 4 (Year) Repeated Measures ANOVA for Reading, Math, Language Arts, and Total Battery Achievement Scaled Scores Total Number of Students Placed in Special Education Programs for the 1990-91 through 1997-98 School Years Results of Chi-Square Analyses for Placement in Special Education Programs for the 1990-91 through 1997-98 School Years Total Number of Students Promoted and Retained for the 1990-91 through 1997-98 School Years Results of Chi-Square Analyses for Promotion Status for the 199091 through 1997-98 School Years Total Number of Students Placed in Drop-Out Prevention Programs for the 1990-91 through 1997-98 School Years Results of Chi-Square Analyses for Placement in Drop-Out Prevention Programs for the 1992-93 through 1997-98 School Years 20 29 33 34 35 36 38 42 42 43 44 45 45

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v Table 14 Means and Standard Deviations for Number of Disciplinary Referrals Received During the 1989-90 through 1997-98 School Years 46 Table 15 Means and Standard Deviations for Number of Days Suspended During the 1990-91 through 1997-98 School Years 47 Table 16 Values of Cronbach’s Alpha for Combinations of Teacher Perception Items for the 1990-91 through 1995-96 School Years 48 Table 17 Means and Standard Deviations for Teacher Perception Domain During the 1990-91 through 1995-96 School Years 48

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vi List of Figures Figure 1 Figure 2 Figure 3 Figure 4 Reading Achievement Scale Scores for the 1992-93 through 199697 School Years Math Achievement Scale Scores for the 1992-93 through 1996-97 School Years Language Arts Achievement Scale Scores for the 1992-93 through 1996-97 School Years Total Battery Scale Scores for the 1992-93 through 1996-97 School Years 38 39 40 41

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vii School Functioning of Children with Asthma: A Study of the Elementary and Middle School Years Shannon Elizabeth Johansen ABSTRACT This study examined the school functioning of children with asthma compared to the school functioning of children without asthma over a 9-year time span. The present study was a secondary analysis of data from one large school district in a southeastern state. Information was gathered from multiple sources, including student records and parent and teacher surveys. Variables related to academics, behavior, and teacher perception were examined. A total of 646 participants were initially included in the study. These participants included 296 students identified as having asthma and 350 students identified as not having asthma. Participants were matched on gender, race, and socioeconomic status. Results of this study indicated significant differences for various years and subjects on a standardized achievement test. However, computed effect sizes were quite low, suggesting no practical difference between the groups. Additionally, rates of special education placement differed for the groups for one school year. All other years and variables indicated no significant differences between the groups. These findings suggest that educational experience of children with asthma may not differ significantly from that of their peers without asthma. However, future research should attempt to

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viii measure variables in different ways and possibly examine cases in a more qualitative manner.

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1 Chapter 1 Introduction The physical and emotional stressors that are caused by chronic illness can affect all aspects of a person’s life. One of the most important experiences of childhood is education. While this it typically a positive experience for most children, students battling chronic illnesses often have many factors to deal with that could possibly have a negative effect on their education. It is important to consider the educational experiences of children with chronic illnesses and how these findings can lead to successful interventions. Asthma is the most common chronic illness affecting children in the United States (Butz, Malveaux, Eggleston, Thompson, Huss, Kolodner, & Rand, 1995). Currently, the occurrence of this illness is rising, especially among inner-city, African-American children (National Institutes of Health, 2000). Asthma is a markedly variable condition, with symptoms ranging from mild to very severe. Numerous studies examining schoolage (ages 5-18) children have found that asthma significantly affects psychological functioning. Many studies examining the psychological functioning of children with asthma have used assessment tools found to be both valid and reliable, such as the Child Behavior Checklist and the Piers-Harris Children’s Self-Concept Scale. Additionally, many of these studies were well-designed and included matched control groups who did not have any chronic illnesses. Overall, the results of these studies suggest that children with asthma often exhibit high levels of depression, anxiety, phobias, and social

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2 withdrawal, along with lower levels of self-esteem (Bennett, 1994; Kashani, Konig, Shepperd, Wilfley, & Morris, 1988; MacLean, Perrin, Gortmaker, & Pierre, 1992; Mrazek, Schuman, & Klinnert, 1998; Nelms, 1989; Padur, Rapoff, Houston, Barnard, Danovsky, Olson, Moore, Vats, & Lieberman, 1995). Consequently, it can be assumed that children with asthma may experience an increased number of difficulties at school. Further information about this population of students is needed to ensure that the needs of these children are being fully met. Rationale While numerous studies have focused on the psychological and social functioning of children with asthma, very few studies have examined the impact of asthma on the educational experience of children. The lack of research on this topic may be due to the recent advances in medical technology and health care that have made more children with asthma able to participate in the many activities related to childhood, such as school. The few studies that have explored this topic have examined absentee rates (Bender, 1999; Celano & Geller, 1993; Folwer, Davenport, & Barg, 1992; Gutstadt, Gillette, Mrazek, Fukuhara, LaBrecque, & Strunk, 1989), peer acceptance (Graetz & Shute, 1995; Nassau & Drotar, 1995), learning problems in school (Fowler, Davenport, & Garg, 1992; Tonnessen, 1994), and parental perceptions of children’s educational experiences (Fowler, Davenport, & Garg, 1992; Nassau & Drotar, 1995; Tonnesson, 1994). However, more research is needed on the overall impact of asthma on the educational experience. Although some studies have examined the educational experience of children with asthma at a specific point in their educational career, no known studies have followed children with asthma throughout their entire educational experience.

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3 Collecting longitudinal data on this population of students will help parents, teachers, and other education professionals to understand the overall school functioning of children with asthma across the school age years. The current study utilized longitudinal data to analyze variables related to academics, behavior, and teacher perception. Achievement, special education placement, number of grade retentions, placement in drop-out prevention programs, disciplinary referrals, and suspensions was analyzed. Teacher perception of students’ (a) ability to pay attention, (b) behavior in school, and (c) overall success in school was analyzed within the teacher perception domain. Purpose This study examined the school functioning of children with asthma compared to the school functioning of their same-age peers without asthma over a 9-year time span. The study determined if there was a significant difference between these two groups in the areas of academics, behavior, and/or teacher perception domains. The present study was a secondary analysis of data from one large school district in a southeastern state. These longitudinal data included information related to the educational experience of students over a 9-year time span, following participants from kindergarten through eighth grade. Through the comparison between the groups, attention was directed to the following research questions: 1. Do children with asthma have significantly lower standardized achievement scores in the areas of reading, math, and language arts compared to children without asthma at the elementary and middle school levels? Additionally, are total battery scores on a standardized achievement test significantly lower for

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4 children with asthma compared to children without asthma at the elementary and middle school levels? 2. Are children with asthma placed in special education significantly more than children without asthma at the elementary and middle school levels? 3. Are children with asthma retained significantly more than children without asthma at the elementary and middle school levels? 4. Are children with asthma placed in drop-out prevention programs significantly more than children without asthma at the elementary and middle school levels? 5. Do children with asthma receive disciplinary referrals significantly more than children without asthma at the elementary and middle school levels? 6. Are children with asthma suspended significantly more than children without asthma at the elementary and middle school levels? 7. Do teachers’ perceptions of students’ ability to pay attention at school, students’ overall behavior in school, and students’ potential for an overall successful school experience differ significantly for children with asthma compared to children without asthma at the elementary and middle school levels?

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5 Chapter II Review of Literature Recent advances in the fields of medical technology and health care have significantly improved the lives of children with chronic illnesses. Not only have these advances prolonged the lives of many children, but those living with chronic illness have experienced an improved quality of life. Consequently, more children who are chronically ill are able to attend school, play sports, and enjoy the many aspects of childhood (Power, McGoey, Heathfield, & Blum, 1999). However, since these advances are fairly recent, research that informs the question of how children with chronic illnesses fare in settings such as public schools is still relatively new. Although the physical effects of chronic illness can be devastating, the educational effects can be equally overwhelming. As a result, it is essential for parents, teachers, and other professionals within the field of education to understand the impact of chronic illness on school-age children and the overall outcome this can have on children’s functioning within the educational setting. Asthma is the most common illness affecting children in the United States (Butz et al., 1995). Numerous studies have focused on the impact of asthma on the psychological and social functioning of children. For example, research exploring the psychological effects of asthma has found that children with asthma are at an increased risk for internalizing behaviors, such as depression, somatic complaints, and social withdrawal (Bennett, 1994; Kashani, Konig, Shepperd, Wilfley, & Morris, 1988;

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6 MacLean, Perrin, Gortmaker, & Pierre, 1992; Mrazek et al., 1998; Nelms, 1989). Research also has investigated the effects of asthma on the self-esteem of children, concluding that children with asthma typically score lower than healthy children on scales of self-esteem. Missing significant amounts of school, being limited in certain activities, and feelings of helplessness may lead to these types of internalizing behaviors (Padur et al., 1995). The social functioning of children with asthma, although frequently researched, has not been found to be significantly different from the social functioning of healthy children. Although children with asthma are viewed by their classmates as having greater levels of illness, being hospitalized more, and being a less preferred playmate, these children have not been found to have poorer peer relationships, fewer friendships, or feel lonelier than their healthy peers (Graetz & Shute, 1995). Additionally, scales completed by parents and teachers also support the assertion that children with asthma do not experience difficulties in the area of social competence (Nassau & Drotar, 1995). While a substantial amount of research has focused on the psychological and social outcomes of childhood asthma, few investigations have concentrated on looking specifically at the educational experience of these children. This chapter reviews the existing literature investigating the school functioning of children with asthma. This chapter has been divided into five sections: (a) prevalence and definition, (b) symptoms and treatment, (c) academics, (d) behavior, and (e) teacher perception. Prevalence and Definition According to the Centers for Disease Control and Prevention (CDC), in 2001 asthma occurred at a rate of 126 per 1,000 children between the ages of 0 and 17. The

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7 rate of asthma among adults occurred at a rate of 109 per 1,000, indicating that the rate of asthma in children is quite high (CDC, 2001). Since 1980, the prevalence rate of asthma among children between the ages of 5 and 14 years increased by 74%, indicating that this is a growing epidemic. Additionally, rates of asthma are found to be higher among African-American children and females (NIH, 2000). Since asthma is the most common chronic illness experienced by children under the age of 18 years, it is important to consider the educational impact it can have on those living with this illness. According to researchers, asthma is defined as a chronic inflammation disorder that causes airflow obstruction and bronchial hyperresponsiveness to a variety of stimuli (Brown, 1999). Specifically, three physiological changes characterize an asthma attack. First, the lining of the bronchial tubes becomes inflamed, leading to a constricted condition. Second, the small muscles surrounding the bronchi become hypersensitive, reducing airflow further. Finally, glands produce excess mucus secretions further clogging narrowing airways (Phelps, 1998). There are several characteristics that aid in depicting the course of this illness. First, asthma is intermittent, meaning that its attacks generally occur on an aperiodic basis. Second, asthma is variable in that its attacks can range from mild to quite severe. Third, asthma is reversible, meaning that the airways return to their previous condition spontaneously or following treatment (Thompson & Gustafson, 1996). The age of onset of asthma can be somewhat earlier for boys than girls. However, nearly two-thirds of boys and half of girls experience their first asthma attack by the age of 3 years. Furthermore, by the age of 10 years, more than 90% of all children with

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8 asthma have had their first asthmatic attack (Mrazek, Schuman, & Klinnert, 1998). Symptoms and Treatments The symptoms associated with asthma can be devastating for children and adults alike. The most common symptoms of asthma include coughing, wheezing, tightness of the chest, and allergic reactions of the eyes, nose, or skin (Thompson & Gustafson, 1996). Additionally, children with asthma may experience diminished stamina for vigorous exercise and labored breathing. In severe cases, children with asthma may experience cyanosis, which consists of a lack of oxygen that causes the skin to turn blue (Brown, 1999). Asthma may be precipitated by a variety of factors, such as changes in air temperature or humidity, exposure to environmental allergens, exercise, upper respiratory infection, or emotional expressions such as crying or laughing (Thompson & Gustafson, 1996). Treatments for asthma include a variety of methods, including environmental control, pharmacologic management, behavioral interventions, and self-management (Bender, 1995; Thompson & Gustafson, 1996). By controlling the environment in which the child lives, many asthmatic attacks can be prevented. These methods include installing air-filters, limiting exposure to animals, and limiting exposure to dust through cleaning. Additionally, depending on the nature of the child’s symptoms, medications can be used to prevent and manage attacks. Pharmacologic treatment typically includes the use of bronchodilators, anti-inflammatory agents, and mast-cell stabilizer medications (Bender, 1995). Behavioral interventions typically include relaxation techniques, contingency management, and decreasing hospital overuse by decreasing the reinforcing qualities of the hospital. Finally, self-management includes teaching parents and children

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9 how to appropriately deal with asthma attacks and work with physicians to improve the overall quality of life (Thompson & Gustafson, 1996). Achievement Several investigations have asserted that learning problems occur frequently among children with asthma (Tonnessen, 1994). Studies relying on parent questionnaire data typically have concluded that children with asthma experience academic difficulties in school, specifically with reading. Additionally, a study conducted in Sweden investigated the reading achievement of children with asthma. The study included 28 participants, ages 8 through 15, attending a special school for children diagnosed with severe asthma. Reading achievement was assessed by the administration of a computerbased test battery containing a word recognition test and a non-word reading test. Additionally, the parents of the students completed questionnaires designed to assess the prevalence of immune disorders and reading difficulties among the other family members. Results indicated that the proportion of students with reading problems was much higher than would be expected in the normal population. This was particularly true for phonological problems. Additionally, there was found to be an elevated incidence of both reading problems and immune disorders among family members. (Tonnessen, 1994). In contrast, several studies that have assessed academic achievement in children with asthma by using the results of objective, standardized tests do not typically support the conclusion that this group of children is at risk for academic problems. For example, one study including 99 hospitalized children with moderately severe to severe asthma found that average scores on the Slosson Intelligence Test, Woodcock Johnson Reading

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10 Mastery Test, Woodcock Johnson Psychoeducational Battery (Part II), and Key Math Diagnostic Arithmetic Test fell above the 50th percentile relative to age-based norms (Gutstadt et al., 1989). Similarly, in a study of children with less severe asthma, it was found that the school administered, standardized achievement test scores of these children did not significantly differ from healthy children (Bender, 1995). In the largest study of children with asthma (1,041 patients in eight cities), mean IQ, cognitive, and achievement scores were normally distributed (Annett, Aylward, Lapidus, Bender, & DuHamel, 2000). These conflicting results may be due to a variety of factors that have been shown to affect the academic achievement of children with asthma. For example, the use of certain medications, such as oral steroids, have been found to impede fine motor skills, be related to lower scores on tests of verbal and visual memory, and increase drowsiness and hyperactivity in children (Bender, 1999; Bender, Lerner, & Polland, 1991; Celano & Geller, 1993). Similarly, some studies have found that the severity of asthma is significantly related to the academic achievement of children with asthma, with children having severe asthma scoring lower on standardized achievement tests compared to children with less severe asthma (Bender, 1995). Special Education Placement Special education placement is an important component of the educational experience for many children. Special education placement related to academic concerns can include placement for specific learning disabilities and mental handicaps. Special education placement related to behavior may include placement for an emotional handicap, ranging in severity from moderate to severe. Numerous studies have assessed the rates of special education placement among children with asthma in a variety of ways.

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11 For example, a comprehensive study of school functioning of children with asthma in the United States found that families reported that 9% of children with asthma had learning disabilities compared to 5% of healthy children (Fowler, Davenport, & Garg, 1992). Similarly, one study examining children with chronic illnesses, including children with asthma, assessed the likelihood of these children being placed in special education. This study found that children with chronic illness had substantially higher odds of being placed in special education than healthy children (odds ratio 2.65; p< .0001) (Gortmaker, Walker, Weitzman, & Sobol, 1990). However, special education placement was assessed by parents answering the following Yes or No item: “Does _____ go to a special class or get special help in school because of a disability or health problem?” This does not assess the specific special education placement or service, which could range from a selfcontained class to a pull-out class for reading or a drop out prevention program. Some researchers also have sought to understand if an asthma-specific learning disability exists. However, there is not clear evidence of this. Most studies that have supported this assumption have relied on data that informally measured students’ learning problems, often by the use of parent interviews (Bender, 1995). Relatively few studies have examined rates of specific placement in special education programs, leaving findings inconclusive. Additionally, although there are some studies that have examined behavior problems of children with asthma, virtually no known studies have examined the behavior of this population of children at school. Most studies concluding that children with asthma have an increased rate of behavior problems have used data from parents,

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12 while few have examined school records and actual placement in special education placement related to behavioral concerns. Retention Research on the topic of grade retention of children with asthma is sparse, possibly due to the few studies that have longitudinally examined the educational experience of children with asthma. In a study that examined data from the 1988 U.S. National Health Interview Survey on Child Health, it was found that children with asthma had higher rates of grade failure (18% vs 15%). Results of this study also concluded that children with asthma from lower income families had a doubled risk for grade failure compared with healthy children from families of similar income (Fowler et al., 1992). However, there were limitations to this research. For example, the information was based on family reports of health conditions and school outcomes. Additionally, the children identified as having asthma may also have had other illnesses that could have played a role in their functioning. The reasons for retention also were not explored. Although there were limitations to this study, it is one of the few studies that has used a representative national sample in order to calculate prevalence estimates. A review of the literature revealed no other studies that have examined this phenomenon to date. This may be due to the fact that many studies utilize participants in elementary school without examining the overall educational experience. Therefore, more data need to be collected in order to better understand the relationship between asthma and retention. Placement in Drop-Out Prevention Programs Placement in drop-out prevention programs for academic concerns is typically related to many of the previously mentioned variables. Students often are placed in these

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13 types of programs in order to promote educational success despite adverse academic experiences in the past. Although many studies have examined variables related to possible future placement in drop-out prevention programs, no known studies have examined the rate of children with asthma being placed in drop-out prevention programs for academic concerns. Drop-out prevention programs also frequently serve children who may be exhibiting risk-taking behavior, such as substance abuse and sexual activity. Despite the higher rates of behavioral problems in children with asthma that some studies have shown, a review of the literature revealed no known studies examining placement of children with asthma in drop-out prevention programs related to behavioral concerns. Absenteeism One major factor that is associated with the educational experience of children who experience chronic illness is school attendance. Research has shown that frequent school absences interrupt the process of learning and interfere with children’s social interactions and participation in extracurricular activities (Padur et al., 1995). Several studies have shown that children with asthma miss school more often than their healthy peers (Bender, 1999; Celano & Geller, 1993; Gutstadt et al., 1989). For example, one study found that children with asthma in one school district missed 7% of the days, while children without asthma missed 2% of the days (Bender, 1999). Data from the 1988 U.S. National Health Interview Survey on Child Health found that children with asthma averaged 7.6 school days absent compared with 2.5 days for the healthy children during the previous 12 month period (Fowler, Davenport, & Garg, 1992). A similar study

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14 revealed that the percentage of days absent for asthmatic children was 7%, compared to 2% for healthy children (Bender, 1999). While it is commonly found that children with asthma tend to miss more school than their healthy peers, research exploring the impact of increased absenteeism has revealed conflicting results. Many studies have found that higher absentee rates among children with asthma adversely affect school grades but do not affect academic achievement as measured by standardized tests (Gutstadt et al., 1989). For example, one Connecticut-based study found that among students with asthma, absentee rates were higher and were significantly associated with lower grades but not decreased achievement scores. However, the grades of children with asthma remained above average, indicating that school absence may temporarily interrupt the acquisition of new skills and knowledge without permanently impeding academic progress (Bender, 1999). Additionally, in a study of 99 moderately severe to severe asthmatic children, Gutstadt and his colleagues (1989) found no statistical correlation between academic performance and school absenteeism. Further, the mean achievement score of the asthmatic group was average or above average despite the children having been absent from school 20% of the days in the semester prior to testing (Gutstadt et al., 1989). Discipline There is limited information related to children with asthma and their behavior at school. Some studies have examined the behavior of children with asthma and any problematic concerns that may be apparent (Gortkaker et al., 1990; Mrazek et al., 1998; Nelms, 1989), but no studies have examined the number of referrals to the office children with asthma receive compared to healthy children. However, due to research indicating

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15 that children with asthma often tend to exhibit more internalizing and externalizing behaviors compared to their healthy counterparts, it can be hypothesized that children with asthma may have a higher rate of referrals for behavior concerns as compared to healthy children (Mrazek, Schuman, & Klinner, 1998). For example, in a study conducted by Gortmaker et al. (1990) it was found that, among 4to 11-year-old children, there was an average of 1.7 more behavior problems indicated among children with a chronic health condition than among healthy children. This study included children with asthma. Additionally, among adolescents with chronic health conditions, behavior problems were 0.9 times more likely to occur in comparison with children without chronic health conditions. Similarly, limited information exists related to children with asthma and suspension. Data from the 1988 U.S. National Health Interview Survey found that rates of suspension and expulsion were nearly similar for children with asthma compared to healthy children (5% vs 6%) (Fowler et al., 1992). However, several studies have found that children with asthma have higher rates of behavior problems compared to healthy children. For example, one study found that an increased number of school-age children with asthma (11.5%) obtained scores above the 98th percentile on the behavior problems portion of the Child Behavior Checklist (CBCL). This rate is twice that found in the general population (Butz et al., 1995). A similar study concluded that children with asthma were at a greater risk for behavior problems than healthy children (Kashani et al., 1988).

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16 Teacher Perception Numerous studies have assessed teachers’ ratings of the psychological and social functioning of children with asthma. However, no known studies to date have examined teachers’ perceptions of children with asthma and their ability to pay attention, although several studies have indicated that children with asthma show increased signs of difficulty paying attention. For example, a study conducted by Butz et al. (1995) found that parents of children with asthma reported that several problem behaviors related to attention occurred “often.” Some of these behaviors included being unable to sit still, being easily distracted, and having trouble paying attention. Parents of children with asthma were significantly more likely to rate their children with these problem behaviors compared to parents of healthy children. There also are no known studies that have examined teachers’ ratings of the overall behavior of children with asthma and their overall potential for success in school. The majority of studies examining the behavior of children with asthma have utilized parent ratings. However, the confidence teachers have in their students and the way they view these children also may be an important factor related to the overall school functioning of children with asthma. This study addresses this gap in literature by examining teachers’ perceptions of children with asthma. Summary Although numerous studies have examined the impact of asthma on the psychological and social functioning of children, few have studied the educational experiences of these children. This may be due to the fact that recent advances in medical technology and health care have increased the quality of life for these children

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17 and allowed them to become more involved in the normal activities associated with childhood, such as school. Numerous studies have found conflicting results when examining the academic achievement of children with asthma in comparison to healthy children. This may be due to the various ways in which academic achievement has been defined and assessed. Similarly, while some studies have informally interviewed parents in an effort to determine the rates children with asthma are placed in special education for both academic and behavioral concerns, few have assessed this by examining actual placement in educational programs. Additionally, a review of the literature revealed no known studies have examined the rate of children with asthma being placed in drop-out prevention programs due to academic and behavioral concerns. These are areas that need to be further explored in order to better understand the needs of this population. Numerous studies have confirmed that children with asthma tend to have higher rates of absenteeism compared to healthy children. This is important because research has found that frequent school absences interrupt the process of learning and interfere with children’s social interactions and participation in extracurricular activities. Additionally, few studies have examined the difference between children with asthma and healthy children on rates of grade retention, disciplinary referrals, and suspensions. Finally, teacher perception of students with asthma has rarely been assessed and is an area that may be very helpful in understanding more about the educational experience of children with asthma. This study addressed the gap in the research on children with asthma in several ways. First, virtually no studies have examined the educational experience of children

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18 with asthma compared to children without asthma from a longitudinal perspective. This study followed students from kindergarten through 8th grade, examining numerous variables related to school functioning. Second, this study clearly defined eligibility for special education services by utilizing the state of Florida eligibility standards. Other studies often have defined disabilities such as learning disability by subjective means, such as parent opinion of their child’s academic functioning. Third, this study examined school outcome variables that have rarely been examined in this population, such as grade retention and rates of suspension. Finally, this study determined if there was a difference between teachers’ perceptions of children with asthma compared to children without asthma.

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19 Chapter III Method This causal comparative study examined differences between children with asthma and children without asthma on variables related to academics, behavior, and teacher perception. A description of participants, measures, procedures, and data analyses involved in this study is provided below. Participants Participants for this study were drawn from students who were included in the database of a large longitudinal study that was begun in 1989. Data collection was conducted at a large urban school district in the southeastern United States. Each year, data were collected from the cohort that began kindergarten in the fall of 1989, a group initially consisting of 8,734 students. These children were followed from kindergarten through 12th grade. These data were gathered from multiple sources, including students, parents, and teachers. A variety of measures were used to gather the information, which explores academic, behavioral, and family domains. Typically, these measures consisted of scales and surveys examining specific variables determined to be of interest that year. The committee who determined these variables, although different from year to year, was typically comprised of school personnel and academic researchers. Additionally, annual data from each student’s school file were available in the database. Information from these files include grades, absences, grade levels retained, discipline referrals, special education placement, and standardized achievement scores. The distributions of the

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20 original sample and the original sample diagnosed with asthma are presented in Table 1 by gender, race, and SES. Six-hundred and forty-six total participants were initially included in this study. Table 1 Distribution of Original Sample by Gender, Race, and SES Original Cohort Original Cohort with Asthma Diagnosis (of the 6,043 returned parent surveys) n % n % Gender Male Female 4238 4496 49 51 221 135 62 38 Race Black White Other 1630 6820 284 19 78 3 100 220 36 28 62 10 SES (Free and Reduced Lunch) No Yes 5172 3562 59 41 206 150 58 42 For the purpose of this study, participants whose parents answered true to the statement “Your child has asthma” on the kindergarten (1989-90) parent survey were selected as the initial asthmatic group. Next, all participants within the initial asthmatic group whose parents indicated on the kindergarten parent survey that their child had ever been hospitalized for any of the following reasons were excluded: allergies, tumor, diabetes, or a heart condition. This decreases the possibility of conditions other than asthma playing a role in various effects. The remaining participants constitute the asthmatic group for this study.

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21 The comparison group for this study was selected by first excluding any participants whose parents answered true to the statement “Your child has asthma.” Next, participants whose parents indicated on the kindergarten parent survey that their child had ever been hospitalized for any of the following reasons: allergies, tumor, diabetes, or a heart condition were excluded. Remaining participants were used to construct the comparison group for the study. Participants within the asthmatic group and the comparison group were matched for gender, grade, race, and socioeconomic status (as measured by eligibility for the Free and Reduced Lunch program). This procedure was completed by first determining the gender, grade, race, and socioeconomic status of each participant in the asthma sample. These participants were then matched one-to-one with participants in the comparison group on the variables of gender, grade, race, school, and socioeconomic status. Due to factors such as students moving to other school districts, more participants were selected for the comparison group to ensure each participant in the asthma group always had a matched participant without asthma. A total of 76 different schools were represented among the participants. Variables In this study, the independent variable was health status (asthma or no asthma). Asthma was defined as a diagnosis of asthma according to parent endorsement of the item “Your child has asthma” on the kindergarten parent survey. Additionally, asthma was defined as not having been hospitalized for any of the following reasons: allergies, tumor, diabetes, or a heart condition. No asthma was defined as no diagnosis of asthma and not having a diagnosis of any other chronic health conditions, such as allergies, tumor, diabetes, or a heart condition, as indicated on the parent survey. The dependent

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22 variables were academic achievement, special education placement, grade retentions, placement in drop-out prevention programs, disciplinary referrals, days suspended, and teacher perception of students’ (a) ability to pay attention, (b) overall behavior, and (c) potential for overall success in school. Academic achievement was measured by the test results of administration of the Comprehensive Test of Basic Skills (CTBS) at the elementary school level (grades 3-5) and the middle school level (grades 6-8). The CTBS is a norm-referenced test that assesses individual achievement in the areas of reading, language arts, math, science and social studies. For the purpose of this study, normal curve equivalent (NCE) and scale scores in the areas of reading, math, language arts, and the battery composite score were used to measure achievement. NCE scores can range from 1 through 99 and a score of 50 is considered average or “on grade level.” Scale scores range from 0 to 999 and are the same for each grade level. Scale scores can be compared at each grade level within the same content area. The CTBS has been found to have strong content and predictive validity and strong reliability (Schell, 1984). Special education placement was determined by school records and was defined by Florida eligibility criteria for placement in the Specific Learning Disabilities, Visually Impaired, Speech Impaired, Language Impaired, Emotionally Handicapped, Gifted, Profound Mentally Handicapped, and Severely Emotionally Disturbed programs during the elementary (grades 1-5) and middle (grades 6-8) school levels. Students may have been placed in one or more of these programs at a given time. Eligibility for services from these programs vary by the type of program. Eligibility was typically determined by evaluation results including psychological testing or medical evaluations.

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23 Grade retention was determined by school records and was defined as repeating a complete grade level of school. Students promoted included those who were promoted both through academic and administrative promotions. Placement in drop-out prevention programs was determined by school records and defined as placement in (a) Educational Alternative Programs, (b) Teenage Parent Programs, (c) Substance Abuse Programs, (d) Disciplinary Programs, (e) Department of Juvenile Justice Programs, and (f) Department of Children and Family Services. Eligibility for these programs typically included resistance to previously implemented interventions and either a school-based team or administrative recommendation for placement in the specific program. These various programs addressed issues ranging from academic remedial instruction to risk-taking behaviors such as substance abuse. Disciplinary referrals were measured by school records and were defined as any type of disciplinary referral that did not result in suspension, expulsion, or reassignment to an alternative program. The number of disciplinary referrals was totaled for the elementary (grades K-5) and middle (grades 6-8) school levels. Behaviors such as disturbing the classroom or noncompliance of a less severe nature typically resulted in disciplinary referrals. Suspension was measured by student records, with suspensions including inschool and out-of-school suspensions. The number of days suspended was totaled for the elementary (grades K-5) and middle (grades 6-8) school levels. Behaviors such as physical aggression toward others typically resulted in either an in-school or out-ofschool suspension The number of days suspended varied depending on the type of behavioral infraction.

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24 Finally, teacher perception of children with asthma included several components. Teacher perception of the students’ overall ability to pay attention was measured by the Omnibus Project Teacher Survey administered each year during grades 1 through 6. Specifically, this item asked “Does this student have difficulty paying attention?” Choices included (1) yes, (2) no, and (3) undecided. Teacher perception of the students’ overall behavior in school was also measured by the Omnibus Project Teacher Survey administered in grades 1 through 6. Specifically, this item asked “Choose the one answer that best describes this student’s behavior in school.” Answer choices included (1) excellent, (2) satisfactory, (3) needs improvement, (4) unsatisfactory. Teacher perception of the student’s overall potential for success was measured by the Omnibus Project Teacher Survey administered in grades 1 through 6. Specifically, this item asked “To what extent do you agree with the statement, ‘This student will have a successful overall school experience?’” Answer choices included (1) strongly agree, (2) agree, (3) undecided, (4) disagree, (5) strongly disagree. All data in the teacher perception domain were assessed by computing a mean score across the elementary (grades 1-5) and middle (grade 6) school grade levels for each variable. All data in the teacher perception domain were recoded for the data analysis. Specifically, responses were recoded such that a teacher endorsement of descriptions of positive student behavior received codes of small numerical values (0, 1) while the values became increasingly larger (4, 5) as the behaviors became more negative or inappropriate. Procedure This study was a secondary analysis of data collected from a longitudinal research project conducted in a large school district in the southeastern United States. As

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25 described above, each year, data were collected on the cohort of students who entered kindergarten in 1989. These students completed 12th grade during the 2001-2002 school year, although this varies due to drop out and retention. Each year, parent, teacher, and student surveys were completed. The parent surveys were handed out to the students at school who then took them home, had the parents fill them out, then returned them to school through the students. Some schools offered small incentives for students to return the surveys, such as pencils, bookmarks, or magnets. Of the 8,734 parent surveys that were distributed to the original cohort of students, 6,043 were returned. The teacher surveys were sent out to the schools by the school district’s internal mail system and completed on the teachers’ own time or when students were completing their surveys. Once completed and returned, all surveys were returned to the main research administrative office through the internal mail system. Additionally, students’ school records were available for analysis each year. Permission for the research reported in this paper was obtained from the school district that has collected and maintained the longitudinal data. This was obtained by providing the project manager with a summary of the proposed topic of research, the purpose of the study, specific questions and hypotheses, the sampling method, the statistical procedures that would be utilized, the anticipated results, the time frame for the study, the services that would be requested, and the benefits to the district or educational community. Once permission from the project manager was obtained, the necessary data was requested. The project manager first selected the asthmatic and comparison groups. The project manager then matched these participants one-to-one on the variables of gender, grade, race, and socioeconomic status. The project manager then compiled the

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26 data for each participant on the following variables: reading achievement, math achievement, language achievement, overall achievement, special education placement, grade retention, placement in drop-out prevention programs, disciplinary referrals, days suspended, and teacher perception of students’ (a) ability to pay attention, (b) overall behavior, and (c) overall potential for a successful school experience. The project manager then compiled this information onto floppy disks, which was given to the researcher for data analysis. Data Analysis First, frequency distributions were examined for all participants on the following variables: school attended, gender, race, socioeconomic status, promotion status for grades Kindergarten through 8 (data are missing for grade 7), special education placement in grades Kindergarten through 8, drop-out prevention program placement in grades Kindergarten through 8 (data are missing for grade 7), number of disciplinary referrals for grades 1 through 8, number of suspensions for grades 1 through 8, and teacher perception scores on teacher completed surveys related to attention, overall behavior, and potential for success for grades 1 through 5. As mentioned above, data were not available for the 1996-97 (grade 7) school year due to an error in the initial data input. Next, the teacher perception items were recoded in order to ensure that they would be scaled consistently. The three individual teacher perception items were combined to form the teacher perception domain. These individual items included the questions included on the teacher surveys administered each year that related to students’ ability to pay attention, students’ overall behavior, and students’ overall potential for a

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27 successful school experience. Next, reliability analyses were computed for the combined teacher perception domains for each year ranging from 1990 through 1995.

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28 Chapter IV Results The participants in this study are presented in Table 2 by gender, race, and SES. Two-hundred and ninety-six students were identified as having asthma during the 19891990 school year, while 350 students were selected as the comparison group and identified as not having asthma. There were significantly more males (61%) identified as having asthma compared to females (39%). The majority of participants were White (71%), while African-Americans made up 26% and Asians, Hispanics, and Indians made up the remaining 3% of the participants. Socioeconomic status was measured by eligibility for Free and Reduced Lunch. The majority of students (55%) did not apply for the program, while 38% qualified for reduced lunch and 7% qualified for free lunch.

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29 Table 2 Distribution of Selected Partic ipants by Gender, Race, and SES No Asthma Asthma n % n % Gender Male Female 182 168 52 48 180 116 61 39 Race Black White Asian Hispanic Indian 81 261 4 4 0 23 75 1 1 0 87 199 4 5 1 29 67 1 2 <1 SES (Free and Reduced Lunch) Did not apply Reduced lunch Free lunch 195 130 25 56 37 7 162 116 18 55 39 6 Question I: Do children with asthma have significantly lower standardized achievement scores in reading, math, and language arts compared to children without asthma at the elementary and middle school levels? Are total battery scores on a standardized achievement test significantly lower for children with asthma compared to children without asthma at the elementary and middle school levels? Independent t tests were conducted to test differences in the mean NCE scores in the areas of reading, math, language arts, and the total battery for children with and without asthma. NCE scores can range from 1 through 99. A score of 50 is considered average or “on grade level.” Due to an error in the original set of data, math scores were not available for this analysis. Specifically, it appeared that math stanine scores were inputted into the original database rather than NCE scores. As seen in Tables 3 and 4,

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30 scores for children with and without asthma were typically within the average range and usually did not differ significantly. However, there were several instances in which these groups did demonstrate statistically significant difference in mean scores. The formula utilized to compute the standardized effect size was as follows: Mean nonasthma – Mean asthma pooled standard deviations Cohen’s general guidelines regarding effect sizes indicate small effect sizes as being below 0.2, moderate effect sizes being between 0.2 and 0.5, and large effect sizes being between 0.5 and 0.8. For the purpose of this study, significant differences with moderate to large effect sizes will be considered practical differences. During the 1993-94 school year, children with asthma ( M = 48.63, SD = 23.31) had significantly lower NCE reading scores than children without asthma ( M = 53.87, SD = 21.62), t (455) = 2.49, p = .01. The degree of difference was calculated using the standardized effect size, es = .23, which was relatively low. During the 1993-94 school year, children with asthma ( M = 48.70, SD = 24.45) had significantly lower NCE language arts scores than the children without asthma ( M = 55.39, SD = 21.15), t (451) = 3.10, p = .002. Again, the degree of difference was calculated using the standardized effect size, es = .29, which was also relatively low. Similarly, during the 1994-95 school year, children with asthma ( M = 53.18, SD = 22.17) had significantly lower NCE language arts scores than the children without asthma ( M = 57.52, SD = 20.22), t (418) = 2.10, p = .037. This standardized effect size, es = .20, was also relatively low. During the 1992-93 school year, the total battery NCE scores were significantly lower for children with asthma ( M = 53.54, SD = 23.94) compared to children without asthma ( M = 57.95, SD = 23.38), t (469) = 2.02, p = .044. A relatively low standardized effect size, es

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31 = .19, was again calculated. Finally, the 1993-94 total battery NCE scores were significantly lower for children with asthma ( M = 49.91, SD = 23.78) compared to children without asthma ( M = 55.38, SD = 22.19), t (448) = 2.52, p = .012. The standardized effect size for this difference, es = .24, was relatively low. Similarly, when analyzing scale scores, several differences were found. The 1992-93 math scale score was significantly lower for children with asthma ( M = 681.03, SD = 61.62) compared to children without asthma ( M = 692.25, SD = 58.51), t (469) = 2.03, p = .043. The standardized effect size for this difference was relatively low, es = .19. Additionally, the 1992-93 total battery scale scores were found to be lower for children with asthma ( M = 685.35, SD = 50.62) compared to children without asthma ( M = 695.10, SD = 48.83), t (467) = 2.12, p = .034. This standardized effect size of .20 was also low. The 1993-94 reading scale scores were found to be significantly lower for children with asthma ( M = 687.04, SD = 59.24) compared to children without asthma ( M = 700.44, SD = 51.71), t (440) = 2.57, p = .011. This standardized effect size was also low, es = .24. Additionally, the 1993-94 language arts scale scores were found to be significantly lower for children with asthma ( M = 697.92, SD = 54.70) compared to children without asthma ( M = 714.32, SD = 44.85), t (429) = 3.48, p = 0.01. Again, the standardized effect size of .33 was low. The 1993-94 total battery scale scores were found to be significantly lower for children with asthma ( M = 694.31, SD = 50.06) compared to children without asthma ( M = 705.93, SD = 44.57), t(446) = 2.60, p = .010. This standardized effect size was also low, es = .24. Finally, the 1994-95 language arts scale scores were found to be significantly lower for children with asthma ( M = 723.85, SD = 47.98) compared to children without asthma ( M = 734.08, SD = 42.04), t (416) =

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32 2.33, p = .021. Again, the standardized effect size of .23 was low. Due to an error in the original input of data, scores were not obtained for the 1998-98 school year. All effect sizes are summarized in Table 5. As seen in Table 6, the skewness and kurtosis of the NCE scores indicate approximately normal distributions of CTBS scores across both the asthma and nonasthma groups. Again, math NCE scores were unavailable. Additionally, a 2 (asthma) x 5 (year) repeated measures analysis of variance (asthma x year) was computed for the reading, math, language arts, and total battery scale scores to determine the difference between the asthma and no asthma groups and their change in scores over time. As seen in Figures 1, 2 and 3, and Tables 4 and 7, scores increased each year, but there was no significant difference between groups in the area of academic achievement or between the groups in academic achievement by year.

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33 Table 3 Means and Standard Deviations for Reading, Math, Language Arts, and Total Battery CTBS NCE Scores for the 1992-93 through 1997-98 School Years No Asthma Asthma M SD M SD t p Reading 1992-93 (n = 472) Reading 1993-94 (n = 455) Reading 1994-95 (n = 419) Reading 1995-96 (n = 369) Reading 1996-97 (n = 375) Reading 1997-98 (n = 368) Math 1992-93 (n = 460) Math 1993-94 (n = 437) Math 1994-95 (n = 410) Math 1995-96 (n = 371) Math 1996-97 (n = 365) Math 1997-98 (n = 367) L. Arts 1992-93 (n = 470) L. Arts 1993-94 (n = 451) L. Arts 1994-95 (n = 418) L. Arts 1995-96 (n = 369) L. Arts 1996-97 (n = 375) L. Arts 1997-98 (n = 364) Battery 1992-93 (n = 469) Battery 1993-94 (n = 448) Battery 1994-95 (n = 417) Battery 1995-96 (n = 365) Battery 1996-97 (n = 372) Battery 1997-98 (n = 359) 55.90 53.87 53.78 53.40 55.69 56.41 ------56.49 55.39 57.52 52.81 54.18 54.47 57.95 55.38 56.47 54.48 55.72 56.29 21.12 21.62 20.86 20.79 21.98 23.19 ------24.31 21.15 20.22 22.97 25.08 23.59 23.38 22.19 20.69 22.58 23.38 23.55 52.47 48.63 50.62 53.75 54.79 56.73 ------52.51 48.70 53.18 50.84 51.13 53.11 53.54 49.91 52.68 52.53 53.32 55.93 22.59 23.31 21.69 19.38 21.05 23.74 ------23.66 24.45 22.17 22.55 22.04 22.76 23.94 23.78 22.31 21.64 22.08 22.90 1.71 2.49 1.52 -0.16 0.40 -0.13 ------1.80 3.10 2.10 0.83 1.25 0.56 2.02 2.52 1.80 0.84 1.02 0.15 .089 .013 .129 .870 .686 .895 ------.073 .002 .037 .407 .211 .577 .044 .012 .073 .403 .310 .883 Note. Dashes indicate that data were not obtained.

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34 Table 4 Means and Standard Deviations for Reading, Math, Language Arts, and Total Battery CTBS Scale Scores for the 1992-93 through 1997-98 School Years No Asthma Asthma M SD M SD t p Reading 1992-93 (n = 472) Reading 1993-94 (n = 455) Reading 1994-95 (n = 419) Reading 1995-96 (n = 369) Reading 1996-97 (n = 375) Reading 1997-98 Math 1992-93 (n = 471) Math 1993-94 (n = 452) Math 1994-95 (n = 418) Math 1995-96 (n = 371) Math 1996-97 (n = 376) Math 1997-98 L. Arts 1992-93 (n = 470) L. Arts 1993-94 (n = 451) L. Arts 1994-95 (n = 418) L. Arts 1995-96 (n = 369) L. Arts 1996-97 (n = 375) L. Arts 1997-98 Battery 1992-93 (n = 469) Battery 1993-94 (n = 448) Battery 1994-95 (n = 417) Battery 1995-96 (n = 365) Battery 1996-97 (n = 372) Battery 1997-98 688.21 700.44 723.58 743.86 754.90 -692.25 704.48 734.25 754.61 768.97 -704.75 714.32 734.08 740.02 751.45 -695.10 705.93 730.50 746.15 758.38 -49.42 51.71 44.91 42.36 46.02 -58.51 51.53 43.07 48.63 53.08 -51.23 44.85 42.02 48.81 54.58 -48.83 44.57 39.58 41.79 45.29 -679.25 687.05 715.53 744.60 753.12 -681.03 695.81 727.98 746.11 765.09 -696.17 697.92 723.85 736.44 745.81 -685.35 694.31 722.33 742.90 754.07 -56.13 59.24 50.49 37.53 41.94 -61.62 50.49 45.38 51.93 53.78 -49.70 54.70 47.98 47.64 47.40 -50.62 50.06 43.37 39.90 42.19 -1.84 2.57 1.73 0.18 0.39 -2.03 1.81 1.45 1.63 0.70 -1.84 3.48 2.33 0.71 1.06 -2.12 2.60 2.00 0.76 0.95 -.066 .011 .085 .861 .697 -.043 .071 .148 .104 .483 -.066 .001 .021 .478 .289 -.034 .010 .046 .448 .345 -Note. Dashes indicate that data were not obtained.

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35 Table 5 Effect Sizes for Statistically Significant Differences Among CTBS Scores Subject Area and School Year Effect Size Math NCE 1992-93 Total Battery NCE 1992-93 Reading NCE 1993-94 Language Arts NCE 1993-94 Math NCE 1993-94 Total Battery NCE 1993-94 Language Arts NCE 1994-95 Math Scale Score 1992-93 Total Battery Scale Score 1992-93 Reading Scale Score 1993-94 Language Arts Scale Score 1993-94 Total Battery Scale Score 1993-94 Language Arts Scale Score 1994-95 Total Battery Scale Score 1994-95 .21 .19 .23 .29 .21 .24 .20 .19 .20 .24 .33 .24 .23 .20

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36 Table 6 Skewness and Kurtosis of CTBS NCE Scores No Asthma No Asthma Reading NCE 1992-93 n Skewness Kurtosis Language Arts NCE 1992-93 n Skewness Kurtosis Total Battery NCE 1992-93 n Skewness Kurtosis Reading NCE 1993-94 n Skewness Kurtosis Language Arts NCE 1993-94 n Skewness Kurtosis Total Battery NCE 1993-94 n Skewness Kurtosis Reading NCE 1994-95 n Skewness Kurtosis Language Arts NCE 1994-95 n Skewness Kurtosis Total Battery NCE 1994-95 n Skewness Kurtosis 236 .058 -.470 234 -.013 -.852 233 -.082 -.729 231 -.220 -.276 228 .147 -.267 228 -.057 -.586 219 .047 -.396 218 .042 -.216 217 .016 -.314 236 -.009 -.399 236 .013 -.864 236 .006 -.814 224 .003 -.308 223 .079 -.611 220 .001 -.576 200 -.199 -.362 200 -.166 -.372 200 -.078 -.424 Continued on the next page

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37 Table 6 (Continued) No Asthma No Asthma Reading NCE 1995-96 n Skewness Kurtosis Language Arts NCE 1995-96 n Skewness Kurtosis Total Battery NCE 1995-96 n Skewness Kurtosis Reading NCE 1996-97 n Skewness Kurtosis Language Arts NCE 1996-97 n Skewness Kurtosis Total Battery NCE 1996-97 n Skewness Kurtosis Reading NCE 1997-98 n Skewness Kurtosis Language Arts NCE 1997-98 n Skewness Kurtosis Total Battery NCE 1997-98 n Skewness Kurtosis 192 .149 -.265 191 -.237 -.338 189 -.013 -.531 198 -.056 -.383 198 -.006 -.620 198 .024 -.627 196 .042 -.481 195 -.173 -.304 192 .027 -.595 177 .069 -.162 178 -.045 -.240 176 .037 -.294 177 -.051 -.399 177 -.079 -.436 174 .066 -.491 172 -.132 -.486 169 -.118 -.399 167 .099 -.731

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38 Table 7 Results of the 2 (Asthma) x 5 (Year) Repeated Measures ANOVA for Reading, Math, Language Arts, and Total Battery Achievement Scaled Scores Reading Math Language Arts Total Battery F p F p F p F p Asthma 0.00 .984 0.43 .514 0.81 .368 0.34 .559 Year 436.98 .000 456.83.000 184.20.000 716.20.000 Asthma x Year 0.37 .831 0.20 .941 1.12 .346 .59 .672 Figure 1. Reading Achievement Scale Scores for the 1992-93 through 1996-97 School Years 600 620 640 660 680 700 720 740 760 780 800 1992-931993-941994-951995-961996-97 School YearScale Score No Asthma Asthma

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39 Figure 2. Math Achievement Scale Scores for the 1992-93 through 1996-97 School Years 600 620 640 660 680 700 720 740 760 780 800 1992-931993-941994-951995-961996-97 School YearScale Score No Asthma Asthma

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40 Figure 3. Language Arts Achievement Scale Scores for the 1992-93 through 1996-97 School Years 600 620 640 660 680 700 720 740 760 780 800 1992-931993-941994-951995-961996-97School YearScale Score No Asthma Asthma

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41 Figure 4. Total Battery Scale Scores for the 1992-93 through 1996-97 School Years Question II: Are children with asthma placed in special education significantly more than children without asthma at the elementary and middle school levels? Chi-square analyses revealed that children with and without asthma typically did not differ in special education placement (see Tables 8 and 9). However, a difference was noted during the 1994-95 school year. During the 1994-95 school year, children with asthma were placed in special education programs significantly more than children without asthma, x2 = 20.30, p = .03. One-hundred and two (34.5%) of the 296 children with asthma received services through a special education program, while 94 (26.9%) of the children without asthma received services through a special education program. Overall, across the elementary and middle school years, the highest percentage of children were placed in the Specific Learning Disabilities, Speech Impaired, Language Impaired, and Gifted Programs, while the smallest percentages were placed in the 600 620 640 660 680 700 720 740 760 780 800 1992-931993-941994-951995-961996-97 School YearScale Scores No Asthma Asthma

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42 Visually Impaired, Severely Emotionally Disturbed, and the Profound Mentally Handicapped. Table 8 Total Number of Students Placed in Special Education Programs for the 1990-91 through 1997-98 School Years Asthma Special ed. No special ed. No Asthma Special ed. No special ed. N (%) N (%) N (%) N (%) 1990-91 66 (22.3) 230 (77.7) 73 (20.9) 277 (79.1) 1991-92 85 (28.7) 211 (71.3) 93 (26.6) 257 (73.4) 1992-93 94 (31.8) 202 (68.2) 90 (25.7) 260 (74.3) 1993-94 96 (32.4) 200 (67.6) 88 (25.1) 262 (74.9) 1994-95 102 (34.5) 194 (65.5) 94 (26.9) 256 (73.1) 1995-96 94 (20.1) 269 (76.9) 94 (31.8) 202 (68.2) 1996-97 91 (30.7) 205 (69.3) 85 (24.3) 265 (75.7) Table 9 Results of Chi-Square Analyses for Placement in Special Education Programs for the 1990-91 through 1997-98 School Years x2 df p 1990-91 9.62 8 .293 1991-92 11.85 9 .222 1992-93 16.13 10 .096 1993-94 18.24 10 .051 1994-95 20.30 10 .027 1995-96 14.08 9 .119 1996-97 12.39 9 .192 1997-98 9.09 8 .335

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43 Question III: Are children with asthma retain ed significantly more than children without asthma during the elementary and middle school levels? Chi-square analyses revealed that children with and without asthma typically did not differ in the number of times retained in grades 1 through 8. The number of students promoted versus the number of students retained each year is presented in Tables 10 and 11. No data were available for the 1996-97 school year. These data may have been inputted incorrectly when first compiled or unavailable at the time of data collection. Data analysis indicated that most students were academically promoted, while a small percentage were either administratively promoted or retained. Table 10 Total Number of Students Promoted and Retained for the 1990-91 through 1997-98 School Years No Asthma Asthma Promoted N (%) Retained N (%) Promoted N (%) Retained N (%) 1990-91 1991-92 1992-93 1993-94 1994-95 1995-96 1996-97 1997-98 341 (97.4) 348 (99.4) 349 (99.8) 349 (99.7) 350 (100) 340 (97.2) -325 (92.8) 9 (2.6) 2 (0.6) 1 (0.2) 1 (0.3) 0 (0.0) 10 (2.9) -25 (7.1) 285 (96.2) 294 (99.3) 294 (99.3) 296 (100) 296 (100) 287 (97.0) -270 (91.3) 11 (3.7) 2 (0.7) 2 (0.7) 0 (0.0) 0 (0.0) 9 (3.0) -26 (8.8) Note. Dashes indicate that data were not obtained.

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44 Table 11 Results of Chi-Square Analyses for Promotion Status for the 1990-91 through 1997-98 School Years x2 df p 1990-91 3.24 4 .52 1991-92 1.67 3 .64 1992-93 2.74 3 .43 1993-94 2.64 3 .45 1994-95 3.76 2 .15 1995-96 4.33 2 .11 1996-97 ---1997-98 1.77 3 .62 Note. Dashes indicate that data were not obtained. Question IV: Are children with asthma placed in drop-out prevention programs significantly more than children without as thma during the elementary and middle school levels? After analyzing the data related to placement in drop-out prevention programs during the kindergarten through 2nd grade academic levels, it was decided to exclude these years from the data analysis and interpretation due to the fact that drop-out prevention programs were not available to these age groups at that time. As seen in Tables 12 and 13, there was no difference between children with and without asthma in the frequency of placement in drop-out prevention programs. These services varied and included programs such as educational alternative programs and disciplinary programs. The majority of students placed in drop-out prevention programs received services related to academic support, while services related to discipline or at-risk behaviors increased as students were promoted to upper grades (i.e., middle school).

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45 Table 12 Total Number of Students Placed in Drop-Out Prevention Programs for the 1990-91 through 1997-98 School Years No Asthma Asthma Placed N (%) Not placed N (%) Placed N (%) Not placed N (%) 1992-93 1993-94 1994-95 1995-96 1996-97 1997-98 4 (1.20) 24 (6.80) 29 (8.30) 41 (11.9) -41 (11.8) 346 (98.8) 326 (93.2) 321 (91.7) 318 (90.9) -309 (88.2) 29 (9.70) 23 (7.70) 36 (12.2) 29 (9.70) -24 (8.10) 267 (90.3) 273 (92.3) 260 (87.8) 267 (90.3) -272 (91.9) Note. Dashes indicate that data were not obtained. Table 13 Results of Chi-Square Analyses for Placement in Drop-Out Prevention Programs for the 1992-93 through 1997-98 School Years x2 df p 1992-93 5.06 4 .28 1993-94 2.83 4 .59 1994-95 7.35 5 .19 1995-96 7.96 8 .44 1996-97 ---1997-98 11.44 9 .25 Note. Dashes indicate that data were not obtained. Question V: Do children with asthma receive disciplinary referrals significantly more than children without asthma during th e elementary and middle school levels? Independent t -tests were conducted to test differences in the number of disciplinary referrals for children with and without asthma. As seen in Table 14, there

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46 were no significant differences between children with and without asthma in the total number of disciplinary referrals received. Table 14 Means and Standard Deviations for Number of Disciplinary Referrals Received During the 1989-90 through 1997-98 School Years No Asthma Asthma M SD M SD t p 1989-90 (n = 38) 1990-91 (n = 43) 1991-92 (n = 48) 1992-93 (n = 60) 1993-94 (n = 62) 1994-95 (n = 67) 1995-96 (n = 252) 1996-97 (n = 245) 1997-98 (n = 299) 2.78 2.10 2.13 2.14 2.41 2.55 5.73 6.46 7.11 3.38 2.38 1.90 1.85 1.78 2.20 6.71 6.79 9.10 1.67 1.69 2.08 2.56 2.30 2.39 5.21 5.60 6.70 1.11 1.55 1.59 2.22 1.75 1.99 5.58 7.03 7.94 1.23 0.67 0.08 -0.79 0.24 0.31 0.67 1.04 0.42 .227 .508 .935 .431 .813 .761 .501 .297 .678 Question VI: Are children with asthma suspended significantly more days than children without asthma during the elem entary and middle school levels? Independent t -tests were conducted to test differences in the number of total days suspended per year for children with and without asthma. An independent t -test could not be completed for the 1989-90 school year because no variability was present due to the small number of cases ( N = 7). As seen in Table 15, no significant differences were found between the two groups on the number of days suspended each year.

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47 Table 15 Means and Standard Deviations for Number of Days Suspended During the 1990-91 through 1997-98 School Years No Asthma Asthma M SD M SD t p 1990-91 (n = 12) 1991-92 (n = 21) 1992-93 (n = 29) 1993-94 (n = 32) 1994-95 (n = 25) 1995-96 (n = 174) 1996-97 (n = 212) 1997-98 (n = 192) 2.00 2.00 1.69 1.82 1.50 3.78 5.03 3.69 1.00 1.84 1.19 1.02 .905 4.21 4.63 3.35 1.60 1.70 1.62 1.87 1.85 3.87 3.91 3.40 .894 .823 1.66 1.19 1.35 4.07 3.93 3.04 0.71 0.47 0.14 -0.11 -0.75 -0.13 1.89 0.64 .493 .642 .893 .912 .462 .895 .061 .521 Question VII: Do teachers’ perceptions of students differ significantly for children with asthma compared to children without asthma during the elementary and middle school levels? The teacher perception items were first recoded in order to ensure that they would be scaled consistently. The three individual teacher perception items were combined to form the teacher perception domain for each year. Next, reliability analyses were computed for the combined teacher perception domains for each year ranging from 199091 through 1994-95. The standardized alpha was utilized when interpreting the reliability of these domains. As seen in Table 16, the reliability coefficients for the teacher perception domains for each year were relatively high. Next, independent t -tests were run first including all participants and then only including participants who had data for all years within the teacher perception domain. As seen in Table 17, no significant differences were found between the two groups within the teacher perception domain

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48 when analyzing participants with data for each year and scores were within the average range. Table 16 Values of Cronbach’s Alpha for Combinations of Teacher Perception Items for the 199091 through 1995-96 School Years Year 1990-91 1991-92 1992-93 1993-94 1994-95 1995-96 .797 .851 .840 .828 .877 .876 Table 17 Means and Standard Deviations for Teacher Perception Domain During the 1990-91 through 1995-96 School Years No Asthma Asthma M SD M SD t p 1990-91 1991-92 1992-93 1993-94 1994-95 1995-96 -.197 -.189 -.156 -.103 -.046 -.065 .806 .871 .854 .826 .911 .852 -.222 -.208 -.138 -.097 -.015 -.209 .773 .772 .837 .828 .900 .879 0.25 0.18 -0.17 -0.06 -0.27 1.31 .801 .854 .866 .953 .789 .190

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49 Chapter V Discussion The present study utilized longitudinal data to determine the differences between the school functioning of children with asthma compared to the school functioning of children without asthma. Additionally, this study was a secondary analysis of data gathered by a large school district. Consequently, these factors made this study both unique and challenging. This study was unique in the sense that a vast amount of information was available to the researcher to analyze. Additionally, variables were able to be examined over a 9-year time span. Few studies are able to follow children this long throughout the educational experience, which made this study a positive contribution to the literature. However, many challenges arose throughout this study. For example, due to the longitudinal nature of this study, the number of participants decreased as children entered middle school. Additionally, due to the nature of a secondary analysis of data, the researcher was unable to assess some important variables or confidently conclude that other factors (such as the diagnosis of another illness) did not play a major role in the results. Nevertheless, the results of this study offer interesting and important findings and guide future research in this vital area. This study found several significant differences between the two groups in the area of achievement. These differences typically occurred during the beginning elementary school years. However, computed standardized effect sizes were quite low, suggesting a practical difference was not apparent. One explanation for this is the

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50 various methods in which variables have been examined in the past. For example, while some studies have assessed academic achievement by grades or parent input, this study and others that have utilized standardized test scores have found that there is not a strong difference between these groups. This is an important finding because it suggests that the manner in which achievement is assessed can often play a role in the results. For example, it would be helpful to explore other ways to assess academic achievement, such as Curriculum-Based Measurement. Standardized achievement measures are only one way to assess whether children are learning and while these findings were positive for children with asthma, it would be beneficial to assess achievement in other ways. The other area in which a significant difference was found between the two groups was in the area of special education placement for the 1994-95 school year. It is interesting to consider why there was a significant difference for only one year. It can be hypothesized that services to children with illnesses may have differed that year compared to other years, possibly affecting their success in school and need for special services. It is also important to note that eligibility criteria for special education can change from year to year, which also may have played a role in the difference. Additionally, it should be mentioned that Gifted was included in special education placement. While all other areas within special education placement indicate a need for services due to academic, behavioral, or physical needs, Gifted indicates a need for accelerated instruction. Consequently, it cannot be assumed that special education placement only represents difficulty in school because many of these students were also receiving services through Gifted.

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51 Additionally, no significant difference was found between children with asthma and children without asthma on the variable of grade retention. Again, past studies have often asked parents whether their child was ever retained, while this study utilized student records. Several areas were examined that have previously not received a great deal of attention from researchers. Placement in drop-out prevention programs, the number of disciplinary referrals and suspensions, and teacher perception were not found to differ for children with asthma when compared to children without asthma. While previous studies have suggested that children with asthma may demonstrate more negative behaviors than their healthy peers, this study did not find a significant difference within the educational setting. These are very positive findings for children with asthma and their families and suggest that children with asthma have the capability to have an overall successful educational experience. Limitations When interpreting the results of this study, it will be important to consider the limitations of this research. First, this study is a secondary analysis of existing data. Consequently, the researcher did not have control over the sampling strategy, instrument selection, or the data collection process. Consequently, although it was possible to identify children whose parents identified them as having asthma in kindergarten, it was difficult to clearly define the asthma group and comparison group for the overall study. For example, it was not possible to identify any students who may have developed asthma later in childhood. Additionally, it was not possible to determine if children in either of the groups later developed any chronic illnesses, although it was possible to

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52 determine if they had been hospitalized for various illnesses prior to kindergarten. Not knowing whether other illnesses developed in participants later in the study made the differentiation between the asthma group and the comparison group less clear. Second, the number of participants in this study decreased as the students entered the middle school level. This was likely due to students moving to another school district. Additionally, some students had missing data related to the dependent variables. For example, a student may have been absent the day the reading portion of the CTBS, resulting in a missing score for that particular participant. These participants were excluded from the analyses examining the variables they were missing. Third, participants in this study were from one large school district in a southeastern state. Consequently, the results of this study are limited to this specific population and cannot be generalized to the general population. One reason for this is that many counties, school districts, and states differ in the services provided to children with chronic illnesses. Consequently, students with chronic illnesses in other school districts may receive more or less support and opportunities to succeed compared to students within the school district used for this study. Additionally, eligibility for special education services is often defined differently depending on location. For example, the criteria to meet a diagnosis for a Specific Learning Disability differ from state to state. Consequently, a child who qualifies for services in Florida may not qualify for these services in another state, causing the results of this study to only be specific to children in this location. A fourth major limitation of this study is the inability to assess the number of days absent for each participant. While it was the plan of the researcher to analyze the

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53 difference between the number of days absent for children with asthma and children without asthma, more detailed examination of the data did not allow for this. Due to the lack of absenteeism data, a very crucial variable was excluded from this study. While this may have been more detrimental if significant differences were found between the groups (and analyses would have been conducted to determine if the number of days absent negatively affected these variables), this is still considered a major limitation of the study. Similarly, a fifth major limitation of this study is the inability to assess the severity level of each child with asthma involved in the study. Many past studies have assessed severity by a combination of the number of school absences, number of hospitalizations for asthma, type and dosage of medication, and parent ratings. For example, Huberty, Austin, Huster, and Dunn (2000) explored changes in asthmatic condition severity in relation to numerous variables. Results showed that change in condition severity was significantly related to changes in overall academic performance, how well the child was learning, appropriate behavior, and total adaptive functioning. Similarly, in a study examining behavior problems and asthma severity, it was found that children classified with a high level of asthma symptoms were more than twice as likely to experience behavior problems than children classified with a low level of asthma symptoms (Butz et al., 1995). The information available in the database used in this study did not permit accurate measurement of severity. Consequently, children with very mild asthma to very severe asthma were included in the asthma group. A sixth major limitation of this study is the inability to assess the exact age of onset of asthma. The age of asthma onset has been found to significantly affect

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54 behavioral adjustment in children. For example, past research has shown that children who had an early onset of asthma (by 3 years of age) had significantly more behavior problems at age 4 than children who developed asthma later (between 3 and 6 years of age) (Mrazek, Schuman, & Klinnert, 1998). Some of the behavior problems children with early asthma onset experienced included waking at night, depressed mood, and some indication of increased fearfulness (Mrazek, Schuman, & Klinnert, 1998). Due to the nature of this secondary analysis, age of onset was not explored. Finally, the type of treatment participants were receiving for their asthma also was not assessed due to this being a secondary analysis of data. This is a limitation because various studies have shown that some medications used to treat asthma may have negative side effects related to the educational experience. For example, beta-agonists, one of the most commonly used treatments for children with asthma, have been shown to slightly impede fine motor skills, such as writing and drawing, immediately after being inhaled. However, this side effect often diminishes within 30 minutes for most children (Bender, 1999). Corticosteroids, the single most powerful agent used to fight bronchial inflammation, have been reported to increase anxiety and depressive feelings in children. Additionally, subtle neurocognitive changes also have been detected in children with asthma receiving steroids. For example, scores on tests of verbal and visual memory have been found to drop significantly during periods of high dose steroid treatment (Bender, Lerner, & Polland, 1991). However, these effects were absent one day after the cessation of steroid treatment (Seuss, Stump, Chai, & Kalisker, 1986). Other medications used to treat asthma, such as antihistamines and theophylline, have also been found to

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55 have some negative side effects on school performance, such as drowsiness and hyperactivity (Celano & Geller, 1993). Contributions to the Literature Due to the recent advances in the fields of medical technology and health care, students with chronic illnesses such as asthma have been given the opportunity to participate in an increased number of activities related to childhood, such as school. This is a very positive advancement for children who often struggle to have their medical needs met. However, a gap in the research related to children with chronic illnesses currently exists. While there are a significant amount of studies examining the psychological and social functioning of children with asthma, very few explore the educational experiences of these children. Additionally, no known studies have examined the educational experiences of this population of students longitudinally. This study addresses the gap in the research by examining the educational experience of children with asthma through multiple methods, such as standardized test results, review of student records, and surveys. This study also utilized multiple sources, such as teachers and parents. The longitudinal nature of the study allowed for examination of the entire educational experience of these students and how they compare to children without any diagnosed chronic illnesses. This study is not only a contribution to the field of school psychology, but it will also aid parents, teachers, students, and educational professionals in understanding the possible educational outcomes for students with asthma and the areas where interventions need to be implemented. While this study found that the functioning of children with asthma appears to be commensurate to that of children without asthma, additional

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56 research is needed in other areas related to the educational experience, such as peer interactions, participation in extracurricular activities, and leadership skills. Additionally, future research is needed to examine children at other grade levels, such as prekindergarten and high school. It would also be highly beneficial to examine children with illnesses in a more qualitative manner, due to the variability of this illness, and assess achievement in other manners, such as Curriculum-Based Measurement. Each child who enters school is entitled to a positive educational experience and researchers must continue to examine the possible effects not only asthma, but other chronic illness can have on this experience.

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57 References Annett, R.D., Aylward, E. H., Lapidus, J., Bender, B. G., & DuHamel, T. (2000). Pediatric neurocognitive functioning in mild and moderate asthma in the childhood asthma management program. The Childhood Asthma Management Program (CAMP) Research Group. Journal of Allergy and Clinical Immunology, 105 (4), 717-724. Bender, B. G. (1995). Are asthmatic children educationally handicapped ? School Psychology Quarterly, 10 (4), 274-291. Bender, B. G. (1999). Learning disorders associated with asthma and allergies. School Psychology Review, 28 (2), 204-214. Bender, B. G., Lerner, J. A., & Polland, J. E. (1991). Association between corticosteroids and psychologic change in hospitalized asthmatic children. Annals of Allergy, 66, 414-419. Bennett, D. S. (1994). Depression among children with chronic medical problems: A meta-analysis. Journal of Pediatric Psychology, 19 (2), 149-169. Brown, R. T. (1999). Cognitive aspects of chronic illness in children. New York: The Guilford Press. Butz, A. M., Malveaux, F. J., Eggleston, P., Thompson, L., Huss, K., Koloder, K., & Rand, C. S. (1995). Social factors associated with behavioral problems in children with asthma. Clinical Pediatrics, 34 (11), 581-590. Celano, M. P., & Geller, R. J. (1993). Learning, school performance, and children with asthma: How much at risk? Journal of Learning Disabilities, 26 (1), 23-32. Fowler, M. G., Davenport, M. G., & Garg, R. (1992). School functioning of US children with asthma Pediatrics,90, 939-944. Gortmaker, S. L., Walker, D. K., Weitzman, M., Sobol, A. M. (1990). Chronic conditions, socioeconomic risks, and behavioral problems in children and adolescents. Pediatrics, 85 (3), 267-276. Graetz, B., & Shute, R. (1995). Assessment of peer relationships in children with asthma. Journal of Pediatric Psychology, 20 (2), 205-216.

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58 Gutstadt, K. W., Gillette, J. W., Mrazek, D. A., Fukuhara, J. T., LaBrecque, J. F., & Strunk, R. C. (1989). Determinants of school performance in children with chronic asthma. American Journal of Diseases in Children, 143, 471-475. Huberty, T. J., Austin, J. K., Huster, G. A., & Dunn, D. W. (2000). Relations of change in achievement-related behavior in children with asthma or epilepsy. Journal of School Psychology, 38 (3), 259-276. Kashani, J. H., Konig, P., Shepperd, J. A., Wilfley, D., & Morris, D. A. (1988). Psychopathology and self-concept in asthmatic children. Journal of Pediatric Psychology, 13 (4), 509-520. MacLean, W. E., Perrin, J. M., Gortmaker, S., & Pierre, C. B. (1992). Psychological adjustment of children with asthma: Effects of illness severity and recent stressful life events. Journal of Pediatric Psychology, 17 (2), 159-171. Mrazek, D. A., Schuman, W. B., & Klinnert, M. (1998). Early asthma onset: Risk of emotional and behavioral difficulties Journal of Child Psychology and Psychiatry, 39 (2), 247-254. Nassau, J. H., & Drotar, D. (1995). Social competence in children with IDDM and asthma: Child, teacher, and parent reports of children’s social adjustment, social performance, and social skills. Journal of Pediatric Psychology, 20 (2), 187-204. National Institutes of Health. (2000). Online. http://www.nih.gov/ Nelms, B. C. (1989). Emotional behaviors of chronically ill children. Journal of Abnormal Child Psychology, 17 (6), 657-668. Padur, J. S., Rapoff, M. A., Houston, B. K., Barnard, M., Danovsky, M., Olson, N. Y., Moore, W. V., Vats, T. S., & Lieberman, B. (1995). Psychosocial adjustment and the role of functional status for children with asthma. Journal of Asthma, 32 (5), 345-353. Phelps, L. (1998). Health-related disorders in children and adolescents: A compilation of 96 rare and common disorders. Washington DC: American Psychological Association. Power, T. J., Heathfield, L. T., McGoey, K. E., & Blum, N. J. (1999). Managing and preventing chronic health problems in children and youth: School psychology’s expanded mission. School Psychology Review, 28, 251-263. Schell, L. M. (1984). Comprehensive Test of Basic Skills. Journal of Reading, 27, 586589.

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59 Suess, W. M., Stump, N., Chai, H., & Kalisker, A. (1986). Mneumonic effects of asthma medication in children. Journal of Asthma, 23, 291-296. Thompson, R. J., & Gustafson, K. E. (1996). Adaptation to chronic childhood illness. Washington DC: American Psychological Association. Tonnessen, F. E. (1994). Immune disorders and dyslexia: A study of asthmatic children and their families. Reading and Writing: An Interdisciplinary Journal, 6 (2), 151160.

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