Poor Health Is Driving Chronic Absenteeism Among High Schoolers — Here's How Pediatricians Can Help

One in five high school students is likely to be chronically absent, meaning they miss more than 14 school days in the school year. The COVID-19 pandemic served as a catalyst to an already growing problem of chronic absenteeism, leading to an increase from 8 million to 10 million children missing school in the U.S. But this problem isn’t one that only affects educators and school systems; it’s something care providers and health systems should be focused on. Children are absent for many complex reasons, but health is a driving factor. Even more concerning is that chronic absenteeism is linked to poor health outcomes and shorter lifespan later in life. Investing in a child’s education is investing in their health.

Why are students chronically absent?

A student’s health is directly related to school attendance. Chronic disability, poor mental or physical health of a student or caregiver, and teenage pregnancy are top contributors to significant absenteeism. Students with chronic diseases and disabilities are more likely than their healthier counterparts to: repeat a grade, have parent-reported academic challenges, illness-related school absences, and poor mental health. Childhood asthma is one of the most common medical reason why students miss school — in the U.S. data shows that schoolchildren miss a combined 14 million days of school each year because of asthma, much of which can be prevented because asthma is both manageable and treatable . Moreover, students who must board in a healthcare facility can be subject to long stays, often with inadequate resources to support their learning.

Other reasons for chronic absenteeism include trauma — meaning, for example, exposure to violence, bullying, adverse childhood experiences, and authoritative disciplinary actions — and socioeconomic inequities, including lack of transportation, changing schools within short periods of time, and chronic poor health stemming from living in areas of concentrated poverty. In addition, systemic racism baked into U.S. education systems continues to create poor school outcomes for students affected by absenteeism. Given these reasons, chronic absenteeism is disproportionately high among children from low-income families, Black, Hispanic, Native American, and Pacific Islander families, other structurally marginalized populations — especially high among children who occupy intersections of these social identities.

All of these reasons why children are often absent from school are also things that their family doctor or pediatrician should be aware of because they are common social determinants of health.

What are the health implications of chronic absenteeism?

A study of public school students in Utah found that an incidence of chronic absenteeism, even in a single year between eighth and twelfth grade, was associated with a sevenfold increase in the likelihood of dropping out. Kindergarteners and first graders who miss school are less likely to achieve the important milestone of reading by grade 3, making them four times more likely to drop out of high school than their peers. Why does that matter? People who are better educated are more likely to live healthier and longer lives, and adults with less education are more likely to die prematurely. For example, a college graduate, on average, lives approximately nine years longer than someone who drops out of high school. Even infant mortality rate is higher among children born to women who dropped out of high school.

Chronic absenteeism brings a lot more than just academic loss. School is the dominant social and cultural environment to which children are exposed — it’s a place that offers safety, and the only hot meal that many students see during the week. Students who miss the benefits of structured curriculum and group-based learning can pick up negative perceptions by others as less reliable or capable of taking on leadership roles or other advantageous opportunities.

Childhood asthma is one of the most common medical reason why students miss school — in the U.S. data shows that schoolchildren miss a combined 14 million days of school each year because of asthma, much of which can be prevented because asthma is both manageable and treatable.

The psychological burden of missing school can be heavy. Chronically absent students see their entire routines and social support systems disrupted; all their friends or teachers are either cut off or their communication changes significantly. This can cause negative mental health outcomes such as developmental regression, extreme boredom, and disruptive sleep schedules.

What can care pediatricians do about chronic absenteeism?

Pediatricians and family doctors are in an opportune position to intervene in school absenteeism, as they often meet with their patients in regular intervals and have insight into their health and social needs. Providers must treat school attendance as another vital sign, like blood pressure and temperature —  using it as a measure of risk and contextualization for whatever concerns the patient is presenting with.

The American Academy of Pediatrics (AAP) released guidance in 2019 on how to help children and families improve school attendance. They recommend using doctor’s visits as opportunities to discuss absenteeism and raise questions about the potential underlying reasons why their patient is missing school — i.e. asking about bullying and home life. Pediatricians must empower parents to seek the rights that they’re entitled to, listen thoughtfully to their concerns, and consider how intersectionality plays into their school attendance. The AAP also advises that doctors speak to parents, caregivers, or key family members about the importance of school attendance and its link to outcomes later in life.

Pediatricians and family doctors are in an opportune position to intervene in school absenteeism, as they often meet with their patients in regular intervals and have insight into their health and social needs.Click To Tweet

Care providers within schools are also key. A higher number of school-based physicians or school nurses — especially for schools in historically oppressed or underserved communities — could help reduce absences. In one study, 95% of students seen by a school nurse for injury or illness returned to class, compared with 82% of students seen by a school employee not medically certified or licensed who were sent home. A core example is with asthma, one of the leading causes of childhood absence from school: Having a full-time school nurse reduces illness-related absences for students with asthma compared to having part-time school nurses.

What can healthcare systems do to reduce school absences?

Institutional solutions that include data sharing and improved communication across multiple child serving sectors can allow for better reporting and comprehensive care for our patients. Physicians must continue breaking down the walls between Family Educational Rights and Privacy Act (FERPA) and HIPAA so students with chronic illness and hospital stays do not fall behind if and when they miss school.

There are currently existing programs and processes to support students with chronic illness or long hospital stays.

Individualized educational programs (IEPs) tailor a child’s educational goals to their personal needs, primarily for developmental or intellectual disabilities. They are useful for planning and implementing different behavioral interventions or redirecting focus or for communicating during school to better facilitate a learning environment. These same strategies can fit well in long hospital admissions.

603 CMR 28 is an important special education law pertaining to students accessing education while in the hospital or homebound. It is a physician-driven process, and any student that has or is expected to miss 14 days of school is eligible. Physicians initiate the process of hospital education as soon as they know the student will be eligible. The physician completes form 28R3 and submits it to the child’s school principal before in-hospital education services can begin. This law applies to all children, including those not accessing special education services and guarantees hospital and home-bound education.

95% of students seen by a school nurse for injury or illness returned to class, compared with 82% of students seen by a school employee not medically certified or licensed who were sent home.

Looking to future innovations, more can be done institutionally to support chronically absent students.

For example, value-based care reimbursement strategies could reward healthcare systems for promoting positive pediatric outcomes, including school attendance and graduation. There could be inpatient solutions, such as like hospital-based classrooms and tutoring by teachers hired by the hospital, volunteers providing homework help, the utilization of online tutoring services, and access to computers and tablets for schoolwork.

More generally, increased funding and support of research and management of the drivers of chronic absenteeism (i.e. mental health conditions, dysmenorrhea, sickle cell disease, adolescent pregnancy) can address the upstream factors of missing school Similarly making disability justice a stronger priority will also prove to be beneficial in decreasing chronic absenteeism.