August 2011, VOLUME128 /ISSUE 2

School Outcomes of Children With Special Health Care Needs

  1. Christopher B. Forrest, MD, PhDa,b,
  2. Katherine B. Bevans, PhDa,b,
  3. Anne W. Riley, PhDc,
  4. Richard Crespo, PhDd,
  5. Thomas A. Louis, PhDe
  1. aThe Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
  2. bDepartment of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania;
  3. cDepartment of Population and Family Health Sciences and
  4. eDepartment of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; and
  5. dDepartment of Family and Community Medicine, Marshall University School of Medicine, Huntington, West Virginia


OBJECTIVE: To examine the associations between having a special health care need and school outcomes measured as attendance, student engagement, behavioral threats to achievement, and academic achievement.

PARTICIPANTS AND METHODS: A total of 1457 children in the fourth through sixth grades from 34 schools in 3 school districts and their parents provided survey data; parents completed the Children With Special Health Care Needs Screener. School records were abstracted for attendance, grades, and standardized achievement test scores.

RESULTS: Across 34 schools, 33% of children screened positive for special health care needs. After adjusting for sociodemographic and school effects, children with special health care needs had lower motivation to do well in school, more disruptive behaviors, and more frequent experiences as a bully victim. They experienced significantly lower academic achievement, as measured by grades, standardized testing, and parental-assessed academic performance. These findings were observed for children who qualified as having a special health care need because they had functional limitations attributed to a chronic illness or a behavioral health problem but not for those who qualified only because they took prescription medications.

CONCLUSIONS: Specific subgroups of children with special health care needs are at increased risk for poor school outcomes. Health and school professionals will need to collaborate to identify these children early, intervene with appropriate medical and educational services, and monitor long-term outcomes.

  • children with special health care needs
  • student engagement
  • academic achievement
  • bullying
  • school performance
  • middle childhood
  • adolescence
  • school outcomes


Using a noncategorical approach to identifying children with special health care needs, previous research has shown that these individuals are at increased risk for poor health and high health care resource use.


Children who screen positive for a special health care need because of functional limitations or behavioral health problems are at risk for low student engagement, disruptive behaviors, poor grades, and below-average performance on standardized achievement tests.

There is little dispute among education1 and health care2,3 leaders that the health of children and their school performance are dynamically intertwined. Common wisdom holds that good health is a prerequisite for optimal learning, and successful students experience better health. Health may directly affect children's cognitive and socioemotional learning capabilities, their engagement in the learning process, and their desire to learn.4

However, the pathways linking child health with academic performance are not well established. Research has found weak effects between chronic disease and lower reading and math achievement among children aged 5 to 9 years.5 Asthma6,,9 and obesity10,11 seem not to be associated with academic performance. On the other hand, children with attention deficit/hyperactivity disorder perform more poorly on standardized testing and receive lower grades than those without attention deficit/hyperactivity disorder.12,13

Because there are thousands of different pediatric chronic conditions, most of which are rare diseases, it is unlikely that there will ever be enough research to characterize the links between specific long-term disorders and children's school outcomes. An alternate approach uses a noncategorical method for identifying a child as having a special health care need (SHCN). These children include those with long-term physical, emotional, behavioral, and developmental disorders that require prescription medications and medical or educational services or affect a child's functional status.14 Data from the 2003 National Survey of Children's Health indicates that 20% of children aged 6 to 17 years have an SHCN.15 Although much is known about the medical care service needs and use of children with SHCNs, there is scant information on their school outcomes.

Conventional school outcomes include attendance, grades, and standardized achievement test scores. However, the quality of a child's school experience depends on far more than test scores and grades. Schools address children's need for mastery, competence, control, and belongingness, which contribute to academic engagement and learning motivation.16 Engaged and motivated students are interested in learning and experience a sense of security and belongingness in school. They are more likely to exhibit achievement-oriented behaviors (ie, effort, attention, participation) and less likely to behave in ways that compromise their school success (ie, aggression, rule breaking).17,,19

Children with SHCNs can face significant barriers to obtaining high-quality school experiences. They may have learning challenges or behaviors that are difficult for teachers and peers to understand. They often require substantial medical, instructional, and behavioral support and may have individualized education programs.20,,22 If these needs are unmet, children with long-term disorders may feel that they lack the capacity to control their scholastic performance, lose interest in academic work, perceive schoolwork as having little immediate or long-term value, and feel socially isolated within the school community.16 Over time, these conditions coalesce with many other challenges associated with having a chronic disorder, thereby increasing the risk for skills deficits and student disengagement.23

This article presents results from Project Healthy Pathways on the association between having an SHCN and school outcomes among fourth- through sixth-grade students in 3 school districts. The goal of Project Healthy Pathways is to elucidate the effects of child health on school outcomes as children enter adolescence and transition from elementary to middle school. We conceptualized school outcomes as comprising attendance, engagement in schoolwork, behavioral threats to achievement, and academic achievement.


Setting and Subject Recruitment

The study took place in 2 school districts located on the Eastern Shore of Maryland (Dorchester and Caroline Counties) and 1 school district in the southern portion of West Virginia (Wayne County). School districts were rural, with a high proportion of low-income families. The 3 districts included a total of 34 schools, 10 of which were middle schools, 23 elementary schools, and 1 kindergarten-through-eighth-grade school.

Study procedures were approved by the school districts and the institutional review boards of the Children's Hospital of Philadelphia, the Johns Hopkins Bloomberg School of Public Health, and Marshall University. Consent forms were distributed to the parents of students in regular fourth-, fifth-, and sixth-grade classrooms. Although children in self-contained special-education classrooms were excluded, those within an individualized education program in a regular classroom were potentially included in the sample. Special-education categories were unknown because, in accordance with the Family Education Rights and Privacy Act, parental consent permitted access to students' cumulative files but not to separately maintained special-education records. Nonresponders to the initial consent distribution received a duplicate form and a follow-up telephone call. The parents of 74% of eligible students provided consent to participate (Dorchester County: 74%; Caroline County: 76%; and Wayne County: 71%).

Data Collection

Table 1 summarizes the data-collection methodology and study variables by data source and school district. Students in 25 of 34 participating schools (2 school districts) completed a Web-based, audio, computer-assisted, self-administered interview. In each of the remaining 9 schools, the school system's computer network security was unable to support Web-based data collection; therefore, children in the fourth and fifth grades completed a paper-and-pencil questionnaire as a survey administrator read the questions aloud, whereas sixth-grade students completed a self-administered paper-and-pencil questionnaire. Psychometric evaluation of the Healthy Pathways Child Report items and scales using the same study sample revealed no differential item functioning by administration modality.24 There were no differences in achievement and attendance data completeness across the 3 school districts.


Data Collection Methodology and Study Variables by Data Source and School District

On completion of their survey, students delivered questionnaire packets to their parents or guardians. The packets contained a cover letter, signed by the school district superintendent and the principal investigator; the questionnaire itself; and a stamped return envelope. Parents who did not return their questionnaires were sent a postcard reminder. After 6 weeks, local school staff contacted nonrespondents and sent duplicate questionnaires as needed. Parents were mailed a $10 gift card once their questionnaire was received.


Children With Special Health Care Needs

Parents were administered the Children With Special Health Care Needs (CSHCN) Screener, a noncategorical measure of long-term health problems that require health services or cause functional limitations.25,26 The results of the CSHCN Screener are positive if the child has a condition lasting at least 12 months and the parent reports that the child has any 1 of the following qualifying indicators: (1) needs or uses more medical care, mental health, or educational services than is usual for most children of the same age; (2) currently needs or uses medicine prescribed by a doctor, other than vitamins; (3) is limited in his or her ability to do the things most children of the same age can do; (4) needs or gets special therapy, such as physical, occupational, or speech therapy; or (5) has any kind of emotional, developmental, or behavioral problem for which he or she needs treatment or counseling.

Using the CSHCN Screener, we developed 4 variables: (1) the presence of an SHCN (yes or no), which assessed whether a child screened positive to at least 1 of 5 qualifying indicators; (2) the number of SHCN-qualifying indicators a child screened positive to (range: 0–5), which has been associated with increasing medical costs, poorer health status, and greater use of services27; (3) the specific qualifying indicators a child screened positive to (5 separate yes or no variables); and (4) a newly developed measure we termed “SHCN profile types.” The SHCN profile types group children into 5 mutually exclusive categories: (1) functional limitations alone or with any other qualifying indicators; (2) prescription medications only; (3) emotional, developmental, or behavioral problems (any combination except co-occurrence with functional limitations); (4) other; and (5) a “none” category.

We collected information from all parents on whether their child had been diagnosed by a physician to have attention deficit/hyperactivity disorder, learning disabilities, speech problems, an emotional or behavioral problem, and asthma. The results for these condition-specific variables were positive only if parents indicated that their child had problems in the past 12 months with the condition. Using height and weight data obtained from parental report, we calculated the BMI of each child and dichotomized children into obese (≥95th BMI percentile) and nonobese categories.


We summed the number of unexcused and excused absences to measure attendance.

Student Engagement

We conceptualized student engagement as comprising behavioral and affective-cognitive indicators of the investments that children make in school at both classroom and school levels.28,,30 Our measurement of student engagement included behaviors (level of effort applied to schoolwork and attention) and affective-cognitive responses (interest in schoolwork, physical and emotional security, and motivation to succeed in school) that have been previously identified as engagement outcomes.28,29,31

Behavioral Threats to Achievement

Using items from previously developed Healthy Pathways instruments,24 we obtained information from children on their reports of engaging in disruptive behaviors at school, school bullying, and experiences of being bullied at school. For sixth-grade children only, we asked if they carried a weapon to school.

Academic Achievement

Children's standardized test scores in language arts and math were averaged and transformed to a county-grade–specific mean of 100 with an SD of 20. Quarterly grades were coded on a 4-point scale (4 = A, 3 = B, 2 = C, 1 = D, and 0 = F) and averaged for language arts and math. The average of these 2 scores was a child's grade-point average. Parent-assessed academic performance was obtained from a previously developed and validated 6-item scale (range for the item-level mean: 1–5).29 The content of the scale included performance in math, reading, homework, and school work and remembering what was learned.24

Data Analysis

The primary hypothesis we tested in this article is that both the presence and type of SHCN affect school outcomes for children in fourth through sixth grade. Thus, all hypothesis-testing analyses were conducted for the presence of an SHCN and the 5-category SHCN profile types.

Bivariate associations for proportions were estimated using the χ2 statistic. Analysis of variance was used to compare mean values on the school outcomes between SHCN profile types. We used a conservative α value of 0.01 to address the possibility of finding a significant result by chance alone because of multiple comparisons.

Multivariable regression using the generalized estimating equation to adjust SE estimates for clustering of students within schools was conducted for each of the school outcomes. The presence of SHCNs and SHCN profile types were used as independent variables in separate regressions. Analyses controlled for the effects of grade, gender, school, race, maternal educational attainment, and annual family income. We present only those school outcomes significantly associated (P < .01) with either of the SHCN-independent variables.


Of 2124 children whose parents consented to their participation, 98.5% (n = 2091) completed the student questionnaire, 71.9% of the parents completed their questionnaire (n = 1527), and school records were abstracted for 96.0% (n = 2040). There were 1457 children (68.6% of total) with all 3 data sources; this group served as the study sample. There were no significant differences in sociodemographics between the children whose parents completed the parent questionnaire and those who did not.

Table 2 shows the proportions of the total sample (n = 1457) by sociodemographic characteristics and SHCN variables. Overall, 33.3% had an SHCN, approximately one-half of whom (16.1% of all children) were positive on a single SHCN-qualifying indicator.


Children in Fourth Through Sixth Grade by Sociodemographics and SHCN Variables

There were no significant differences in the presence of an SHCN or the SHCN profile types distribution by grade, school district, race, maternal educational attainment, or obesity (Table 3). Boys were twice as likely to have an SHCN as girls. Children in families with annual incomes of <$20 000 were significantly more likely than those with incomes of $80 000 or more to have an SHCN and 4 times as likely to have an emotional or behavioral SHCN.


CSHCNs in Fourth Through Sixth Grade by Sociodemographics and Disordersa

In bivariate analyses, the presence of an SHCN was associated with more days absent, poorer student engagement, more behavioral threats to achievement, and lower academic achievement (Table 4). Children with the functional limitation CSHCN profile type missed 4 more school days per year than counterparts without an SHCN. Individuals in the emotional and behavioral services CSHCN profile type experienced a greater diversity of poor school outcomes than other children with an SHCN. Obesity was not significantly associated with any of the school outcomes, whereas only attendance was associated with asthma (11.6 days missed for children with asthma versus 8.8 days missed for others; P < .001).


Bivariate Associations Between SHCNs and School Outcomes

In multivariable analyses, there were no statistically significant differences associated with the presence of SHCNs or SHCN profile types in attendance, doing extra schoolwork, feeling excited by schoolwork, interest in schoolwork, getting in trouble at school, breaking a rule at school, destroying something at school, or telling someone that you would hurt them by presence of SHCNs or SHCN profile types. The functional limitations and emotional and behavioral services CSHCN profile types had the largest number of associations and the biggest effect sizes in multivariable regression analyses, whereas children in the medication-only profile type had similar outcomes to those without an SHCN (Table 5).


Regression-Adjusted Effects of SHCNs on School Outcomes


Children in the fourth through sixth grades (aged 9–11 years) who screened positive for an SHCN because of functional limitations attributed to chronic illness or behavioral health problems are at increased risk for less student engagement, more exposure to bullying, more disruptive behaviors that threaten social competence, and lower academic achievement. These problems threaten both their well-being as youth and their future flourishing as adults. It is important to note that children who qualified only because they take prescription medications generally had similar school outcomes as those without an SHCN, as did children with obesity and asthma. Thus, long-term disorders do not necessarily affect school performance. Our findings suggest that functional limitations attributed to chronic disease and behavioral health problems comprise the key SHCN subgroups that are at risk for poor school outcomes.

This article extends the literature on the effects of chronic disease on school outcomes by using a noncategorical definition of SHCNs that is based on impact rather than diagnosis.15,25,26 The advantages of the noncategorical approach are its simplicity and practicality, enabling screening to be done in virtually any setting, such as the primary medical home and even schools, while obviating the need for parents to recall specific diagnostic labels.

In the 34 schools in this study, 33% of fourth- through sixth-grade students screened positive for an SHCN. Other studies that have used noncategorical SHCN-screening approaches estimated between 15% and 36%26,32,,34 of school-aged children with an SHCN, variation that is partially a result of the methodology used to characterize the presence of an SHCN.15 Another reason that our estimate is on the high end of this range is that the study sample included a large share of low-income families, who, in this and other research,15 have children with an increased risk of SHCNs. Similar research conducted with more socioeconomically diverse or urban school districts may find different point estimates for the presence of an SHCN and could find different associations between having an SHCN and school outcomes.

The replication of study findings across 3school districts, the large sample size, multiple data sources, and breadth of the statistical associations strengthen our conclusion that CSHCNs are at increased risk for poor school outcomes. Although the CSHCN Screener identifies children with limitations in their functional status, it does not measure variability in the impact of long-term conditions on symptoms and functioning. It is possible that there are thresholds of symptom burden and functional impact that heighten the risk for poor school outcomes. One approach to testing this hypothesis and potentially finding these cut points would be to combine the CSHCN Screener with measures of children's self-reported health.24 Because this research used a cross-sectional study design, we are unable to rule out reverse causation: children with poor school outcomes may be more likely to be labeled as having an SHCN. Future longitudinal research in Project Healthy Pathways will inform directionality of the associations between health and school outcomes.

This work has important implications for the interactions between health and educational professionals when it comes to promoting children's health and learning. One approach for addressing the health and learning needs of the large number of children with emotional and behavioral problems is creating a continuum of mental health care in the school, while linking families, primary medical homes, communities, and schools.34,35 This involves implementing, for example, a universal prevention initiative, such as antibullying programs36,37; establishing in-school mental health counseling; and creating a referral system with community services for students who have needs that cannot be met in school. School services are augmented by collaboration with community mental health, primary care physicians, and parent organizations with the goal of providing a full continuum of services for all children. Unfortunately, there are few examples of such comprehensive, coordinated, and linked school-community initiatives.


Effective health care and educational practice require that children at risk for poor school outcomes be identified early to enable prevention and treatment.35,,37 The current study suggests that the identification of SHCNs, particularly those that manifest themselves as functional limitations or behavioral health problems, should be an essential component of the early intervention process. The identification of children at risk for academic failure requires the coordination of services provided by educators and health professionals. Once identified, schools must provide appropriate educational accommodations and support to ensure that children with SHCNs meet their full potential in learning and scholastic achievement. These services may be provided in a special-education context if children qualify for such services. In addition to specific academic interventions, schools should provide abundant opportunities for children with an SHCN to develop confidence in their ability to learn and succeed in school, choose educational experiences that they value, and develop positive interpersonal relationships at school.16 The logical roles for the primary medical home are early identification of at-risk children, ensuring that chronic conditions and behavioral health problems are managed effectively, and monitoring of long-term outcomes including both health status and school outcomes.41 Health and school professionals will need to work together to identify these children much earlier, ensure that they receive appropriate supports and services, and monitor the effectiveness of services on children's health and school outcomes.


This study was supported by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01HD048850).

Dr Christina Bethell, an Associate Professor in the Department of Pediatrics, School of Medicine at Oregon Health Sciences University, assisted in the analysis of data from the children with special health care needs screener. Anna Brousell of the Children's Hospital of Philadelphia helped with manuscript preparation. We are grateful for the invaluable support and collaboration of our school district colleagues in Caroline County, MD; Dorchester County, MD; and Wayne County, WV. These education and health leaders made this study possible.


    • Accepted April 14, 2011.
  • Address correspondence to Christopher B. Forrest, MD, PhD, Professor, Children's Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104. E-mail: forrestc{at}
  • FINANCIAL DISCLOSURE: The authors have indicated that they have no personal financial relationships relevant to this article to disclose.

  • Abbreviations:
    special health care need
    Children With Special Health Care Needs


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