Asthma and allergies account for one third of all chronic conditions in childhood and affect one out of five school children. A recent survey among school-aged children found that almost 10% had a wheezing illness suggestive of asthma in the previous year.1 As with any chronic illness that may not be adequately controlled, asthma and allergies can create special problems for the child and the school. Many of these problems can be avoided by anticipating some of these potential obstacles and establishing goals for asthmatic and allergic children.
GOALS FOR THE ASTHMATIC AND ALLERGIC CHILD IN SCHOOL
Helping school-aged children meet and maintain the following goals can prevent problems before they occur:
1 . Control asthma and allergy symptoms at school.
2. Provide the opportunity for optimal school performance. This encompasses keeping school absences to a minimum and ensuring that the child's symptoms and medication side effects do not interfere with his or her learning experience or that of others in the classroom.
3. Normalize the asthmatic child's participation in regular physical education to the maximum extent possible.
4- Keep allergen and irritant exposure at school to a minimum.
5. Promote the acceptance of the asthmatic and allergic child by his or her classmates.
WHAT THE PHYSICIAN CAN DO TO AVOID PROBLEMS CAUSED BY ASTHMA/ ALLERGIES IN SCHOOL
Among the potential problems that asthmatic and allergic children may encounter in school are unnecessary asthma morbidity, excessive absenteeism, impaired school performance, impaired participation in physical education, behavioral problems, and feelings of isolation. In addition, patient symptoms may interfere with the learning of other children in the class.
Reducing Unnecessary Asthma Morbidity
With the availability of effective medications for the treatment of asthma, symptoms should be controllable in the majority of patients. Fundamental to the success of therapy is obtaining important information concerning the impact of symptoms on the child's quality of life (Table 1). Effective treatment is also dependent on the management skills of the physician, patient, parent(s), and teachers. Teachers often have the responsibility of supervising asthmatic children during school hours and making decisions regarding physical activities and both emergency and regular drug treatment. Reports indicate that some teachers still receive poor instruction about asthma and its management2 and consequently have a limited understanding of asthma and its management.3 In addition, arrangements for treating asthma when it occurs in school can be unsatisfactory in some areas.4
Functional Assessment of the Asthmatic
Much can be done to reduce unnecessary asthma/ allergy morbidity:
* Encouraging a close working relationship between the physician, the parents, and school officials is important to the successful management of the asthmatic child in school. It is essential for parents of asthmatic children to communicate closely with their child's physician and school. The school should be given information concerning the child's condition including symptom triggers and measures to be taken for avoidance, a list of all the medications the child receives and their potential side effects, treatment plans to follow if the child incurs symptoms while in school, and guidelines to be followed while on field trips. Forms 1 through 3 in the Appendix can be used by the physician to transmit asthma information to the school.
* Because allergen and irritant exposures in the classroom may result in increased symptoms, avoidance measures should be provided to the school when needed.
* Inhaled beta2 adrenergic agents are the cornerstone of asthma therapy and should be made available for use in the schools. Because most asthmatic children do not use the proper technique in administering metered dose inhalers, the use of a spacer device such as Insptrease (Schering Corp; Kenilworth, New Jersey) or Aerochamber (Monagham Medical Corp; Plattsburg, New York) is indicated in most, if not all, cases. The Rotahaler (Alien & Hanburys, Division of Glaxo; Research Triangle Park, North Carolina) is a relatively new method of delivering inhaled albuterol; it is compact, does not require a spacer, and is relatively easy to administer. Children deemed sufficiently responsible should be permitted to selfmedicate. It is usually unnecessary to burden the school with the administration of regularly used medications such as inhaled corticosteroids, cromolyn sodium, or theophylline. Form 4 in the Appendix can be used by the physician to authorize the school to administer as-needed medications.
Resources for Obtaining Asthma Literature
* Because it has been demonstrated that the subjective estimation of the degree of airway obstruction by either the physician or patient is often inaccurate,5 it is important that peak flow meters be available in the school to evaluate the severity of asthma symptoms when they occur. Several inexpensive models are available. Full directions for their use and information concerning interpretation of results should be provided. Form 5 in the Appendix can be used by the physician to transmit information concerning the use of peak flow meters to the schools.
* Several excellent books and informational pamphlets concerning asthma are available for parents and school personnel. In addition, community asthma education programs are conducted in many parts of the country. Table 2 lists organizations that provide information concerning printed materials, videotapes, etc. One of the best references addressing the issues of the asthmatic child in school is a recent publication titled "Asthma in the School: Improving Control With Peak Flow Monitoring."6
* If the patient continues to experience discomforting or disruptive symptoms despite the efforts of the primary care provide:; a second opinion by an asthma specialist should be sought.
Reducing Absenteeism and Maximizing School Performance
Several studies have demonstrated an increased incidence of school absences for children with asthma compared with their nonasthmatic schoolmates.7'9 Parcel et al7 found that the rate of school absences varied directly with the mother's perception of the severity of the child's asthma although the severity was often not substantiated medically. The impact of school absences on academic performance has been studied by several investigators. Whereas some studies demonstrate that children who are absent from school excessively are less likely to graduate from high school and more likely to perform poorly,8'9 Gutstadt et al10 were unable to find a correlation between academic performance and rate of school absence. Nevertheless, there can be little doubt that excessive absences do create special problems for the asthmatic child. Steps to keep school absences to a minimum include:
* Controlling symptoms to the greatest extent possible as described above.
* Establishing specific criteria for keeping or sending a child home because of asthma or allergy. It is important that these criteria not be excessively stringent. For example, if the asthmatic child has mild respiratory symptoms, efforts should be made to medicate the child in school to prevent absenteeism. Likewise, it should be kept in mind that asthmatic children often have symptoms of allergic rhinitis that resemble those of a cold but are not obviously communicable. Even when children have colds, it is often useless to keep them home from school for the sole purpose of preventing the spread of the infection, since by the time it is recognized the child is infected, spread has already taken place. If the child with a cold is comfortable and afebrile, he or she may attend school. Even in the case of acute otitis, the affected child may return to school while receiving antibiotic therapy if symptoms permit.
Several studies have addressed the relationship of school performance to allergies and asthma. Freudenberg et al11 found that 40% of parents of asthmatic children interviewed stated that their child had difficulty in school. Other authors have also reported a connection between allergies/asthma and learning disabilities.12'14 However, McLoughlin et al15 found no significant difference between allergic and nonallergic children in terms of academic and language performance, retention, diagnosis as handicapped, or behavioral problems. Behavioral problems were found in 65% of children due to the medication use. Gutstadt10 found that poor school performance in children with asthma was correlated with low socioeconomic status, older age, history of continuous steroid use (every other day for the previous year), and presence of emotional and behavioral problems. School absences, use of medical resources, oral steroid dosage, other medication used to treat asthma, and pulmonary function were not found to be associated with school performance.
Some of the problems that can specifically affect the performance of allergic and asthmatic children (or their classmates) in school include:
* discomfort and fatigue resulting in the reduction of attention span and the impairment of concentration,
* periodic hearing impairment, a common complication of respiratory allergy,
* drowsiness, nervousness, irritability, and other medication side effects in some children, and
* annoying "allergic" manifestations such as sniffing, "clucking" (palate itch), snorting, sneezing, and coughing.
Several steps can be taken to lessen the adverse effects of asthma and allergy-associated symptoms on school performance:
* ensure that the school has an appreciation of the possible adverse effects of asthma and allergies on the child's school performance and behavior, and that problems are brought to the attention of the parents and physician,
* perform periodic audiologic evaluation in children with associated upper respiratory allergy and make provisions for the afflicted child to sit near the front of the classroom if deficiencies are found while appropriate treatment is started, and
* give school officials information concerning all of the child's medications and their potential side effects (this information should be placed in the patient's school health record).
Facilitating Maximum Participation in Regular Physical Education
Exercise can provoke symptoms in most asthmatic children, depending on the type and duration of exercise, temperature, air pollution level, presence of airborne allergens, and severity of the asthma. Symptoms are more likely to follow running and least likely to follow swimming. However, with close cooperation and communication between physicians, parents, and schools, asthmatic children should be able to participate in most regular physical education activities.
Because it is desirable for asthmatic children to be kept in the mainstream of school activities,16 every effort should be made to encourage their maximal participation in regular physical education. Toward this end several steps can be taken:
* encourage the use of an inhaled beta2 adrenergic agent before exercise to prevent or control exerciseinduced symptoms,
* encourage warm-up exercises before vigorous activity,
* advise the physical education instructor concerning those activities poorly or well tolerated, and assist in determining the level of activity appropriate to the child's asthmatic condition, and
* stress that the asthmatic child should not be transferred to a "corrective" or "modified" program unless absolutely necessary and all avenues of management have been adequately explored.
Form 6 in the Appendix can be used by the physician to transmit recommendations to the physical education instructor. Close communication between the physician, parents, and school personnel is necessary to accomplish these objectives.
Minimizing Behavioral Problems and Classroom Disruption
As discussed above, asthma and allergy symptoms as well as the medications given for these problems can cause irritability and behavioral problems. Furthermore, these symptoms may annoy the patient's classmates, inviting ridicule and contributing to the isolation of an allergic child. Adequate symptom control should help avert many of these problems. The cooperation of school personnel is necessary to ensure that the asthmatic child does not feel isolated. In addition, school officials must stress to the asthmatic child's classmates that asthmatic and allergic children are not "junkies" because they are required to take medication.
1. Gergen PJ, Mullaly DI, Evans R III. National survey of prevalence of asthma among children in the United States. Radiatris. 1988;11:1-7.
2. Storr J, Barrell E, Lenney W. Asthma In primary school. Br Med J. 1987;295:251-252.
3. Bevis M, Taylor B. Whac do school teachers know about asthma! Arch Dis Child. 199165:622-625.
4. Hill RA, Britton JR, Tatfersfield AE. Management of asthma in schools. Arch Dis Child- 1987:62:414-415.
5. Shinn CS, Williams H. Evaluation of the severity of asthma: patients vetsu* physicians, AmJMa), 1980:68:11-13.
6. Mendoza Q, Garcia MK, Colllns MD. Asthma in the School: Improving Control Wild ftat Flow Monitoring. Cedar Grove, N]: HealthScan; 1989.
7. Parcel GS1 Oilman SC, Nader PR1 et al. The comparison of absent« rates of elementary school children with asthma and non-asthmatic schoolmates, Pediatrics. 1979;64:878-881.
8. Mitchell RG, Dawscm B. Educational and social characteristics of children with asthma. Arch Do Child. 1973;41:467-471.
9. Creel TL, Yoches C. The modification of an Inappropriate behavioral pattern in asthma children. Journal of Chronic Diseases. 1971:24:507-513.
10. Gutstadt LB, Gillette JW, Mraiek DA, et al. Determinants of school performance in children with chronic asthma. Am} Da Chad. 1989; 143:47 1-4 7 5.
11. Freudenberg N1 FeldmanCH, Clark NM, et al. The impact of bronchial asthma on school attendance and performance. J Sch Is Health. 1980;50:522-526.
12. Rapaport HG, Flint SH. Is there a relationship between allergy and learning disabilities? J Sen Heath. 1976;46:139.141.
13. Bavard JG. Relationships between allergic conditions and/or learning disabilities. Dis Abs Intern. 197535:6940. Abstract.
14. Rawls DJ, Rowls JR, Harrison CW. An investigation of 6- to 11-year-old children with allergic disorders. J Consult Clin Psychol. 1971;36:260-264.
15. McLoughlin J, Nall M. Isaacs B, et al. The relationship of allergies and allergy treatment with performance and student behavior. Ann ADerp. 1 983 ;5 1:506-510.
16. Committee on Children With Disabilities, Committee on Sporta Medicine. The asthmatic child's participation in sports and physical education. Pediatrics. 1984;74:155-156.
Functional Assessment of the Asthmatic
Resources for Obtaining Asthma Literature