addressing asthma and school performance in urban children

Addressing Asthma and School Performance in Urban Children:

Research, education, and intervention efforts

This webinar is funded by EPA Grant #XA96161601

Thursday, December 12, 2013 9:30 – 10:30 AM EST

Please note that these materials are not to be distributed without

permission.

For more information, please contact Dr. Daphne Koinis Mitchell

[email protected]

mailto:[email protected]

Research, Education and Intervention Efforts to Address Asthma and School

Performance in Urban Children Daphne Koinis Mitchell, Ph.D Associate Professor (Research)

Director, Community Asthma Program Hasbro Children’s Hospital

Department of Psychiatry and Human Behavior (Primary) Department of Pediatrics (Secondary)

Alpert Medical School of Brown University

This work was supported by NICHD; R01 HD057220 (Koinis Mitchell, PI) RI Department of Health Asthma Control Program

Overview ●Effects of Asthma on Urban Children’s School Performance: Recent Data from Project NAPS ● School-based educational initiatives of the Community Asthma Program of Hasbro Children’s Hospital of RI ● Project CASE: Controlling Asthma in Schools Effectively, a multi-level pilot project to enhance asthma control ● Future Directions

The Asthma Health Disparity

● Asthma morbidity higher and poorer asthma control in Latino and African-American Children:

● Higher frequency of ER visits and hospitalizations (US DHHS, 2009; Lara et al., 2009; Ortega et al., 2009)

● Less consistent with taking controller medications (Bauman et al., 2002; Butz et al., 2004; McQuaid et al., 2009; 2012)

The Asthma Health Disparity Disparities are multi-determined Individual (e.g., genetic, Choudhry et al., 2005; high severity, Esteban et

al., 2009; adherence, McQuaid et al., 2009; 2012; poor perceptual accuracy, Fritz et al., 2010).

Environmental (e.g., irritants/allergens, Kattan et al., 2005; violence- related distress, Wright et al., 2004; 2007).

Familial/cultural (e.g., concerns regarding controllers, McQuaid et al., 2009; alternative treatment approaches, Koinis Mitchell et al., 2009; discrimination, acculturative stress and neighborhood stress (Koinis Mitchell et al., 2007, 2009, 2012)

Health care system factors (e.g., public insurance status, lack of consistent PCP, Jandasek et al., 2010; access to a specialist, Canino et al., 2012)

Pediatric Asthma: The Local Burden

In 2010, approximately 12% of children in RI were reported to currently have asthma (higher in urban areas) (RI Dept. of Health, 2012)

In some schools in urban providence, rates

of asthma range from 20-50%

2000 visits for asthma annually in the Hasbro Emergency Department

Urban Children at Increased Risk for Asthma Morbidity, Missed Sleep,

Poor School Performance

● Increased number of school absences, more missed sleep, more activity restriction in children with severe asthma and in urban children (Koinis Mitchell et al; 2007; 2009; 2013)

This group misses more school days (CDC, 2005)

Latino children with asthma are absent more often than whites (Lieu et at . ,

2002)

If not properly treated, can asthma negatively impact children’s ability to learn when in school? Only self-report, cross-sectional studies, inconsistent results

ASTHMA AND ACADEMIC PERFORMANCE IN URBAN CHILDREN

Nocturnal Asthma and

Performance in

School

Brown Medical School/Rhode Island Hospital, Providence RI

R01 (R01-1R01HD057220) Eunice Kennedy Shriver, National Institute of Child Health & Human Development (NICHD)

Daphne Koinis-Mitchell, Ph.D., PI

Project NAPS SPECIFIC AIMS Aim 1: Examine the co-occurrence of asthma status and

academic performance over the school calendar year in a group of urban, elementary school children

Aim 2: Examine mechanisms that mediate the association

between asthma status and academic performance (e.g., sleep quality, allergic rhinitis, and school absences)

Aim 3: Assess contribution of family/cultural risks (e.g.,

perception of severity and levels of fear related to asthma), and AR symptoms on asthma status and academic performance.

NAPS STUDY DESIGN Longitudinal, observational study with repeated measures

255 children (age 7-9 years) with asthma and allergic rhinitis

120 children who are free from chronic illnesses and allergies

Recruited from schools and hospital-based clinics

Children are from 4 adjacent urban school districts

Participant in asthma group have persistent level of disease

All children are from African American, Latino, Non Latino White

TYPES OF DATA COLLECTED:

MULTIMETHOD APPROACH Child & Parent Self report

– Asthma, Allergy, Sleep (Daily Diary), Med. Use, Side Effects, Family Asthma Management, Family/Cultural Risks

Objective Measurements – 1 month, at-home —3 monitoring periods – Pulmonary function (AM2 handheld spirometer; FEV1/FVC/PEF) – Sleep Quality (Actiwatch; Sleep efficiency parameters) – Peak Nasal Inspiratory Flow (In-Check Nasal Flow Meter; PNIF)

Clinical Evaluation – Physical examination (Confirmation of Asthma/AR Diagnosis

classification of AR/Asthma Severity) – Pulmonary function testing – Allergy testing

Academic Data – Teacher Reports: Academic Functioning during 3 monitoring periods – School Nurse Reports: Children’s asthma management at school – Academic Achievement; standardized tests; grades, school absences

HV/Clinic Data

Collection

School/PCP/Nurse Data Collection

Aug 1 – Oct 15 Recruit/Screen Enrollment (S0)

(HV)

Physician Query

Oct 1 – Nov 31 S1 (Clinic Visit)

Mon Per 1 Begins For 4 wks after S1

Monitoring Period 1 Weeks 1 – 4

2 Wks home visit 4 wk home visit

2 wk Teacher Acad Perf Assessment


2 Wks home visit


2 Wks home visit



SNT Packet

June RA

Collects End of School

Year Data

Jan 1 – Feb 28 S2 (Home Visit)

Mon Per 2 Begins

Apr 1 – May 31 S3 (Home Visit)

Mon Per 3 Begins

TIME LINE OF PARTICIPATION

ASTHMA MONITOR (AM2)

The Asthma Monitor AM2 measures and saves all relevant lung function parameters (PEF, FEV1, FVC, MMEF)

AM2 (LUNG FUNCTION) DATA

PEAK NASAL FLOW METER PNIF: Peak Nasal Inspiratory Flow

PNIF measures nasal obstruction and correlates significantly with severity of asthma symptoms.

ACTIWATCH 2

Actiwatch 2 records real-time activity levels that indicate sleep and wake periods over 24 hours.

ACTIWATCH (SLEEP) DATA

HYPOTHESIZED ASSOCIATIONS:

Focus on Asthma and Sleep

Academic Performance

Asthma Status

Sleep Quality

School Absence

Allergic Rhinitis Status

Why Focus on Sleep? Sleep is important for all children (Wolfson & Carskadon, 1998;

Carskadon et al., 2004)

Children with medical conditions miss more sleep if illness is poorly controlled (Boergers & Koinis Mitchell, 2010)

NHLBI (1997; 2007) identified sleep as indicator in assessment of children’s asthma-related adjustment

National Center on Sleep Disorders Research recognized sleep disturbances as an important factor contributing to racial/ethnic disparities in health outcomes (NIH, 2007)

Poor sleep quality is an indicator that asthma is in poor control; relevant for children’s daytime functioning and academic success

Mechanistic Pathways Linking Asthma with Sleep Quality

Asthma symptoms experienced during nighttime hours due to (Meijer et al., 1995) : – Dip in cortisol levels at night; increase in inflammatory cytokines/

mediators – A potential bi-directional relationship with nighttime disturbances

and circadian rhythms (Martin et al., 1998) – Increased airway resistance at night – Increased pollen counts during nighttime hours – Sleep posture facilitates an increase in mucous production – Increased environmental triggers in urban home settings – Nonadherence to treatment

(See review: Koinis Mitchell, Esteban, Craig & Klein, JACI, 2012)

Asthma and sleep not assessed in urban children

Participant Demographics To date, 400 urban families enrolled (275 children with asthma, 125 healthy

controls) ; African American (31%), Latino (51%; Dominican or Puerto Rican) and NLW(18%) backgrounds

Presentation includes data from first 4 years of study; 200 children with asthma

Children between the ages of 7-9 years (Mean=8.4, SD=.9 years)

53% of children are male

67% of families had household incomes below poverty threshold; Ethnic group differences in the proportion of families at/below poverty: Latinos (81%), African Americans (60%), and non Latino whites (39%); (X2 = 20.8; p < .001).

Persistent asthma; classified as Mild Persistent (45%), Moderate Persistent (38%) or Severe (17%). 41% were poorly controlled.

73% (by study clinician) have AR. 72% have persistent symptoms; 47% with moderate, and 18% with severe intensity. 50% of children with AR were never diagnosed. 59% receive no treatment or are undertreated

Objective Lung Function and Sleep Quality

Efficiency through actigraphy = number of minutes during the night coded as sleep – Example: 600 minutes sleep – 60 minutes awake = 540 (90% sleep

efficiency score)

Multi-level Analyses were nested within child

Examined sleep quality within the Sleep Period

FEV1 was significantly associated with sleep efficiency (F=1.6, p<.001) Sleep onset latency (F=3.0, p<.001) Number of night wakings (F=1.4, p<.01)

Diary Reported Asthma Symptoms and Sleep Quality

Analyses were nested within child

Examined sleep quality within the Sleep Period

Self reported asthma symptoms were associated with sleep efficiency (F=1.9)

Sleep onset latency (F=1.5) Number of night wakings (F=1.5, all p’s < .001)

Asthma Control and Sleep Quality

Children with poorly controlled asthma had lower sleep efficiency (F=6.4, p=.01), took more time to fall asleep (F=3.2, p=.05) than children with well controlled asthma

Asthma control associated with sleep duration (F=8.8, p<.01)

Poor asthma control associated with more variability in # of wakings across the monitoring period (F=5.3, p=.02).

Child Sleep Disturbance (Parent Report)

Total Sleep Disturbance Score > 80% of sample scored above the clinical cutoff score of

41 (Owens et al., 2000), indicating marked sleep disturbance in our sample

Total Sleep Disturbance Score significantly associated with

self-reported asthma symptoms: r = .24, p = .03

HYPOTHESIZED ASSOCIATIONS: Focus on Asthma and Academic

Performance

Academic Performance

Asthma Status

Sleep Quality

School Absence

Allergic Rhinitis Status

Impact of Asthma on School Functioning Poorer asthma control associated with more school

absences (β = - .43, t= -2.8, p<.01); relationship more robust for AAs

Children with asthma had a mean of 11 school absences in the year of their study participation (range = 1 – 52 days)

Control participants had an average of 6 absences (range = 0 – 34 days)

Across asthma participants, ethnic differences found in school absences across school year: Latinos: higher rate of absences (M = 13 days,) relative

to AAs (M=8 days), F (2,127)=3.7, p=.03. NLWs did not differ from other groups (m=7 days)

Impact of Asthma and Sleep on School Functioning: Teacher ratings of academic performance More optimal lung function (FEV1) related to higher quality school

work (F=4.7, β =.19, p=.03) and less careless/hasty school work (F=8.1, β =-24, p=.00)

Children with poorly controlled asthma had lower quality school work (F=3.1, β =.18, p=.02) than children with well controlled asthma

Frequency of asthma symptoms by diary report predictive of careless/hasty schoolwork (β =.13, F=2.9, p=.05)

Associations between asthma and academic performance most robust within AA subsample. For example, asthma control significantly predictive of % work completed in AA sample (β =.30, F(1,44)=4.2, p<.05) but not in other ethnic groups

Impact of Asthma and Sleep on School Functioning: Teacher ratings of academic performance

Sleep & Academic Functioning Careless school work associated with poor sleep efficiency (F=8.3, β =

-.23, p<.01), shorter sleep duration (F=5.3, β = -.18, p=.02) and more night wakings (F=5.5, β =.19, p=.02)

The amount of school work completed positively associated (β =.19, p=.02) with sleep efficiency

Children who had fewer struggles staying awake in class had on average, longer sleep duration (F=4.5, β =.17, p=.04)

Impact of Asthma and Sleep on School Functioning: Mediational Analyses

Sleep efficiency significantly mediated the relationship between asthma control and quality of school work (Sobel test=1.9) This result also emerged in the AA subgroup (Sobel test=1.7).

Lung function mediated the association between sleep

duration and school performance (Sobel test = -1.7) in the full sample and in AAs and NLWs

Summary Nocturnal asthma symptoms affect sleep efficiency in this sample of urban

children; More compromised lung function and poor asthma control associated with poorer sleep quality

Children who experienced more optimal lung function performed more

effectively in school Poor sleep quality related to nocturnal asthma affects day-to-day academic

performance Poorer sleep efficiency, shorter sleep duration, and frequent night wakings

associated with problems with children’s academic learning; ethnic minority children appear to be more at risk

Future analyses will be conducted with the larger sample Implications for developing family and school-based interventions to improve

asthma control, sleep quality, and academic performance in urban children

PROJECT NAPS Principal Investigator Daphne Koinis Mitchell, PhD Research Assistants Christine McCue, BA Co-Investigators Katie Dansereau, BA Julie Boergers, PhD Kara Ramos, BA Gregory Fritz, MD Brittney Williams, BA Robert Klein, MD Alvaro Beltran, BA Monique LeBourgeois, PhD Kary Vega, BA Elizabeth McQuaid, PhD Vivian Garcia, BA Ronald Seifer, PhD Jack Nassau, PhD Maria Theresa Coutinho, PhD Barbara Jandasek, PhD

Collaborators/Consultants Project Director Robin Everhart, PhD Sheryl Kopel, MSc Amy Wolfson, PhD

Cynthia Garcia-Coll, PhD Study Clinicians Cynthia Esteban, MSN, MPH Diane Andrade, RN Julia Estrela, RN

Programs Addressing –Asthma at Hasbro

Treatment Education Research/Intervention

The Respiratory and Immunology Center

The Community Asthma Program

The Childhood Asthma

Research Program

Community Asthma Program Hospital and School-based Classes

“102” Classes (For graduates of “101 classes) Asthma Support Groups

Asthma Camp

HARP: Home-based Asthma Response Plan

Project CASE – School Program

Community Asthma Program Staff

Founded by Bob Klein, M.D Daphne Koinis Mitchell, PhD, AE-C Director Miosotis Alsina Coordinator Nico Vehse, M.D. Medical Consultant, Asthma Camp Medical Director Barbara Jandasek, PhD, AE-C Supervisor of Training Elizabeth McQuaid, Ph.D. Previous Director, PI Project HARP

Arelis Valerio, MD, AE-C Diana Jurado Carol Shelton, RRT, AE-C Cathy Kempe, RRT, AE-C Pastora Medina Renata Tejada Nurys Medina de Monsanto Marguerita Arkins

CVS/pharmacy Draw A Breath Program and School Asthma Partnership

Group-based asthma education for families who have children with asthma (parent and child class; 85 classes per year)

Based on NHLBI guidelines, updated annually; Tailored to include relevant barriers

Held at Hasbro and RI Public Schools

Funded through insurance reimbursements and donor support – no out of pocket cost to families

Taxi service and childcare provided

In past 3 years, services provided to over 2000 families

CVS/pharmacy Draw A Breath Program and School Asthma Partnership Parent Education (one class, 1 ½ hrs)

– Classes are offered in English and Spanish – Interpreters arranged as needed – Standard “101” Class and “102”

Child Education

– “Asthma’s Magic Number”, group asthma educational curriculum for children ages 6-12

– “Quest for the Code”, CD-ROM class, co-sponsored by Child Life

Community Asthma Programs: Additional Initiatives

Asthma Camp 35 inner city children with severe asthma

Latino Asthma Support Group 200 families take part in this group annually

Department of Health Collaborations:

– Project CASE: Asthma School Lunch Program » Provide School Staff Trainings, In-school workshops

– HARP Program: Home-based Environmental Control

Asthma Morbidity: Pre-Assessment

56% of caregivers report their child missed at least 10 days of school in past year

50% had an oral steroid in past year

46% had an ER visit in past year

Asthma Management Barriers

17% have a smoker in the home 31% have a pet in the home 30% have a written asthma action plan 7% have seen an asthma specialist

After Participation in Class…

ED visits (n=552, 51% response rate )

Pre-class baseline – 1.28 visits per child

12 month follow-up

– .23 visits per child

583 fewer visits since class cost savings = $179,738

(*calculated using DHS cost for ED visit due to asthma in FY 2000-01)

(Depue et al., 2007)

Average ED Visits Due to Asthma

00.5

11.5

2

Baseline 12-mo follow-up

ED v

isits

in la

st y

ear

2000-01 2001-02 2002-03

Asthma Outcomes: Results maintained (2012) After attending class:

– Parents demonstrate improved asthma knowledge (t=-16.6; p=.0001)

At 4 month follow-up: – Asthma control is improved (t=-5.46; p=.001) – Fewer asthma symptoms (t=-2.1, p<.05) – Decreased ED visits (p=.001)

Future Goals for CAP Reach more families, particularly through our

school-based classes; classes for specific age groups (pre-school; High School)

Enhance link with family’s provider (beyond providing summary letter to pcp?)

Continue evaluation efforts; ED visits from hospital

Continue to reach “hard to reach” families (through home-based and school-based programs; HARP and CASE)

Project CASE: Controlling Asthma in School Effectively

A Collaboration between the RI Department of Health: Asthma

Control Program, and the School Asthma Coalition administered through the RI DOH; a multi-disciplinary community advocacy group comprised of community providers and organizations

CAP at Hasbro Children’s Hospital

Mission of Project CASE To improve asthma outcomes, school functioning and overall health and

well-being of urban children with asthma in the school setting To provide support and training to school personnel in urban settings To enhance communication between caregivers of children with asthma

and school nurse teachers who support urban children with asthma

CASE: Controlling Asthma in School Effectively

Components of Project CASE 1) The provision of guidelines-based asthma education to

children with asthma during the school day in elementary school-settings a) Focus on schools with highest prevalence of asthma and ED use

(through data provided from the Providence plan)

b) Summary of feedback of each child is presented to the school nurse teacher following each class


2) Enhanced linkages between the school nurse teacher and

caregivers; ensuring that each child a) has an asthma action plan at school filled out by their provider b) has an asthma rescue inhaler c) is consistently able to participate in school-based activities

3) The provision of guidelines-based asthma training to

school staff a) School personnel attend training to learn support students’ needs b) review asthma policies/procedures for the management of asthma

in school setting


4) The provision of guidelines-based asthma education to urban caregivers of children with asthma.

-Asthma education provided to the students’ caregivers -Classes are administered after school in students’ school setting 5) Environmental Walk-Thru


We are evaluating the effectiveness of Project CASE

30% of the student body of each elementary school, on average, has

asthma

Of the schools that have participated in the program, SNTs report half the children with asthma, on average, have rescue inhalers in school. 20% have asthma action plans in school

The majority of children don’t self-carry despite self-carry regulation; rescue inhalers are kept in SNTs office

We assist in enhancing school staff’s awareness of how to respond to students’ asthma needs in school


History, Progress and Future Plans

-4th year of Project CASE (previously Asthma Lunch Program) -Program began with pilot funding from the DOH -During first 3 years; 20 during-the day school classes -This year, targeting 4 schools and implementing evaluation

component -High attendance rates; children attend classes in school with

the permission of their caregiver


Long Range Goals: -Expand CASE to more districts and more schools; expand to

middle schools -Continue systematic evaluation efforts of the program -Disseminate program

Putting it all together

Many factors contribute to poor asthma management and morbidity in urban school-aged children

Poor asthma control can affect sleep quality; children’s day to day functioning in school can be compromised, including their learning – Many areas to intervene:

» Focus on home (trigger control, medication use, link with caregiver and SNT)

» Focus on school (availability of action plan, rescue inhaler, awareness of staff, enhance knowledge and efficacy of students, response to symptoms, trigger control in school); SNTS need support

» Enhance collaboration with provider, link with specialist, if needed

Putting it all together – Use Community Asthma Educational Programs as Resource

– Environmental assessment programs- family and school-based

– Consider:

» Children are at school majority of the day. Management practices at home influence child’s sleep and learning (e.g., knowledge of rescue plan, caregivers daily decisions regarding school attendance)

» Identify children who are groggy/sleepy at school may be in poor control

» Families’ connection with SNT is important; Child’s asthma medication should be handy at school and asthma action plan; many barriers

Additional Programs Addressing Students’ Asthma

Asthma, Physical Activity and Obesity (Koinis Mitchell & Jelalian, NHLBI)

Peer-Administered Asthma Self-Management in Urban Middle Schools (Koinis Mitchell & Canino, NICHD)

Asthma and Sleep Intervention for Urban Children (Koinis Mitchell et al, under review)

Questions??

Questions/Feedback

Thank you for participating!

For further questions on this presentation, email Daphne Koinis Mitchell [email protected]

For more information about the Asthma Regional Council of New England,

visit our website: http://www.asthmaregionalcouncil.org

mailto:[email protected]

http://www.asthmaregionalcouncil.org/

addressing asthma and school performance in urban children

Health & Medicine