AAP Voices Blog

As pediatricians who spent many years in school, have children of our own, and take care of school-aged patients, we know there are times a student will miss school. That extra day to visit family after the holiday? Sure. A few days due to an illness? Almost inevitable.

A few missed school days scattered across the year is unlikely to have a major impact on learning. But what if it's a few days a month? What if there are chronic health or social conditions impacting the ability of the child and family to regularly get to school?

As described in a new American Academy of Pediatrics (AAP) policy statement, "The Link Between School Attendance and Good Health," chronic absenteeism, generally defined as missing 10 percent or more of the school year for any reason, can have long-term implications for academic achievement and health outcomes.

Nationally, however, over 6 million children are chronically absent each year, and in our community of Washington, DC, nearly one in three children is chronically absent from school.

Consider David*, a third-grader with a history of asthma, allergic rhinitis, and obesity, who presented mid-winter to our clinic with cold symptoms and wheezing. As part of our assessment to determine control of his asthma, we asked about school absences. His mother tearfully reported that during the first half of the school year, he had already missed about 15 days of school.

As we dig further into his recent asthma history, David's mother acknowledges that the family has struggled with daily adherence to his inhaled corticosteroid and his medication supply has now run out. He has had several asthma exacerbations with acute illnesses this year and suffers from some daily limitations in activities. Further, as the year has progressed, he has felt less engaged at school and reports being bullied.

Especially on days like today, when David wakes up with chest tightness and cough, his mother describes doing mental gymnastics to navigate the logistics and emotions of a safe arrangement for him and his siblings. Would he have access to his inhaler if he had symptoms during the school day? Would kids pick on him for needing to go to the nurse's office? Does his school nurse know his full asthma history and plan of care? If he got worse, who could pick him up from school?

His mother's work schedule is rigid, and transportation is challenging, especially with other children in the household. By her calculation, with the complexity of their daily routines, it is often safer and more convenient to keep him at home if he isn't feeling well.

The family's experience illustrates some of the many factors at play when it comes to school attendance: acute and chronic illness, school connectedness and climate, communication between schools and health care providers and the silos that exist between them, parental work schedules, and transportation.

What does this mean for David? First, he is at a critical pivot point in third grade. Feeling disconnected from his school, curriculum and classmates due to absences puts him at risk for repeating the grade. In addition, his chronic absenteeism this year increases his risk of chronic absenteeism in future years. Failure to graduate from high school puts him at greater risk of poor lifetime health outcomes, including chronic conditions like hypertension and diabetes.

"As pediatricians, we need to view school absenteeism among potential health hazards facing our patients.”

The new policy statement cites research showing education to be a critical social determinant of health, and chronic absenteeism a matter of health equity. School absenteeism disproportionately impacts certain communities, including children with chronic medical conditions and disabilities, children of color, children from low income families or those with housing instability, and children in the juvenile justice system. The report outlines ways to support children and families in managing health and social needs that impact school attendance and long-term health outcomes.

As pediatricians, we need to view school absenteeism among potential health hazards facing our patients. During visits with families, we can routinely ask about and reinforce the importance of school attendance, and educate families on the appropriate reasons to exclude children from school during an acute illness. Pediatric providers also play a critical role in communicating and coordinating with school staff, including school nurses, to manage chronic conditions in school and assist with Individual Education Programs and 504 plans.

At the systems level, we can engage with local school officials and policymakers to advocate for policies, programs, and funding that support attendance, including positive school climate, supportive disciplinary practices, and school-based medical, oral, and behavioral health services. Practices can also consider offering extended hours after school and on weekends to limit the degree to which medical visits contribute to absenteeism.

So, how can we best support David? During the visit, we renew his Asthma Action Plan, refill his medications, and contact the school nurse. Additional screening reveals the family is also experiencing food insecurity, and we connect David's mother with our practice social worker to address transportation and food access. David's school offers mental health supports, and we refer him for services to help address his experiences with bullying. We also remind the family of the evening and weekend hours in our health center so they don't have to miss school and work for sick visits. Finally, a collaborative conversation with the family enables us to highlight the importance of school attendance for David and his academic performance and health, including access to school meals.

As pediatricians, we're committed to working across sectors to advance health equity for all children, and we can play a role in supporting school attendance. Every day counts for children.

*Name has been changed to protect privacy