Minnesota Title V MCH Needs Assessment Fact Sheets

Children with Special Health Needs

School Absences

Summer 2004

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Size of the Problem

An estimated 54,235 children with special health needs missed 5 or more school days in the year surveyed. 32,634 (20.3%) missed 7 or more days of school due to illness or injury.[1]

Children with chronic conditions account for a large share of severe acute illnesses in a community.[2]

Children with chronic health conditions spend most of their day in the school system. The complexity of illness management and disease sequela can alter their school experience.[3] Research has shown that, overall, school professionals have positive attitudes about children with chronic health conditions in the classroom, but concerns about specific diseases and issues exist.[4]

Schools have a responsibility for providing home-based services for children unable to attend for extended periods of time. However, questions have been raised regarding school responsibilities when children with chronic conditions experience excessive absences of brief duration.


Nationally, children with functional limitations are significantly more likely to experience school absences than children with other types of needs.[5] (The same appears to be the case in Minnesota, however, when categorized as such the numbers are too small to be considered reliable.)

Percent of Children with Special Health Needs Missing School by Type of Need (US)

Need Type

Number of Days Missed

0 - 3 days

4 - 6 days

7 - 10 days

11+ days

Functional limitations





Managed by Rx meds





Above routine need/use of services





Rx meds AND service use





Other data suggest that students with serious emotional disturbances miss more days of school per year (an average of 18 days) than do students in any other disability category.

Disparities based on family income also exist. Children living in poverty are more likely to have school absences due to illness than those living at or above the federal poverty level.

The data suggest that children with special needs in Minnesota living in households below the federal poverty level are somewhat less likely to experience excessive absences than children nationally. The likelihood of excessive absences increases as income decreases.

Percent of CSHCN Missing Three Day of School or Less Due to Illness: Nationwide vs. Minnesota X Household Income


0% - 99% FPL

100% - 199% FPL

200% - 399% FPL

400% FPL or greater











In families with children, a close interrelation exists between parent work attendance and child school attendance. Child health can affect parental work attendance, and the health of other family members can affect a child's school attendance. The younger the child, the more likely a school absence will directly impact parental work attendance because younger children require full supervision, even if home because of minor illnesses.[6] Makeup schoolwork is usually required for children who are out of school. This can cause added stress for both child and family.

Environmental Tobacco Smoke exposure is associated with increased respiratory-related school absenteeism among children, especially those with asthma.

Poor health-related behaviors and conditions impede the ability of students to learn and impact attendance. Many students miss valuable educational opportunities because of asthma and upper respiratory infections or are inattentive in class because of poor sleep habits and inadequate nutrition. Some students cannot concentrate because of pain from dental problems or preoccupation with family conflicts, or because they experience real or perceived threats to their safety or lack the interpersonal and social skills needed to function in a modern cooperative classroom. In secondary schools, students who abuse alcohol and other drugs underachieve and cause disruption in the learning environment. Until these and other preventable and treatable health problems are addressed, the ability of most students to master even the best-designed curriculum and perform well on high-stakes tests is compromised.[7]


A study of 835 asthmatic children in grades 2-5 in low-income communities had reduced symptoms and absenteeism and improved academic performance after the implementation of a school-based asthma management program.

Excessive school absence may signal such health problems as poor coping with or poor management of chronic illness, masked depression, teenage pregnancy, substance abuse, inappropriate responses to minor illnesses, or severe family dysfunction. School absence patterns appear to be a readily available, easy-to-use marker of childhood dysfunction. It may also be an indicator of lack of access to health insurance. Attention to this area of child behavior as part of routine health supervision, whether by the school nurse or the physician and will frequently uncover previously unrecognized health problems in children and their families.[8]

School nurses are on the front lines of health care in public schools. The integration of students' health care needs as components of educational programs has become increasingly important as medically fragile children rely on school nurses to deliver or coordinate their health care services.[9] In the case of children with special health care needs, the school nurse, teacher, parent and primary health provider, must develop a coordinated plan of care to address the students' health needs within the school and educational needs during school absences.

Parent and teacher education on early identification of signs and symptoms of acute illnesses is an effective method to decrease the overall length of school absences.

Controlling exposure to acute illnesses has a positive impact on everyone's health, including children with special health care needs. Currently, 69% of states provide training for school staff on infection control guidelines; 48% monitor compliance with such guidelines. Policies must include:

  • Procedures for cleansing and disinfecting tables, desks, etc.;
  • Time to wash hands before eating and after using the bathroom. Schools must assure soap and hot water are available in every bathroom;
  • Time for teacher inservices related to promoting a healthy environment.
  • Age appropriate public health messages such as posters and classroom education regarding the importance of handwashing, coughing into the sleeve instead of hands, and not sharing food or drinks.

Assessing the school environment from the perspective of safety and health can decrease exposure to environmental triggers for conditions such as asthma and allergies. Policies addressing animals in the classroom, for instance, must be implemented.

Transition planning with the school health services provider before returning to school after extended absences should be implemented to assure successful integration back into the school environment.


Schooling affects lifelong health; in general, people who attain higher levels of education tend to live longer. In recognition of this connection, the national health objectives outlined in the U.S. Department of Health and Human Services' Healthy People 2010(2000) include:

  • Increasing the high school completion rate to 90 percent.
  • Increasing the proportion of schools that provide health education to 70 percent to reduce risk behaviors that lead to injury, chronic disease development, and death.
  • Increasing to 50 percent the proportion of schools that have a nurse-to-student ratio of at least 1:750.

However, lack of awareness on the part of parents and the school community, unless they are directly affected, is a problem.

Condition specific advocacy organizations are aware of school health issues related to the chronic illness, but not necessarily those associated with school absences.

There are very few mandates relative to health in schools. Without specific funding, it is unlikely efforts to decrease school absences would be addressed.

1. Data Resource Center for Child and Adolescent Health. National Survey of Children with Special Health Care Needs. CAHMI. http://www.kpchr.org/cshcndrc. [Attn: Non-MDH Link] 5/29/2004.
2. Dosa, N., Boeing, N., Kanter, R. "Excess Risk of Severe Acute Illness in Children With Chronic Health Conditions." PEDIATRICS Vol. 112 No. 6 December 2003, pp. e440-e446.
3. Olson, A., Seidler, B. et al. "School Professionals' Perceptions About the Impact of Chronic Illness in the Classroom." Arch Pediatr Adolesc Med. 2004;158:53-58.
4. Ibid.
5. Data Resource Center for Child and Adolescent Health. National Survey of Children with Special Health Care Needs. CAHMI. http://www.kpchr.org/cshcndrc. [Attn: Non-MDH Link] 5/29/2004.
6. Alberg, A., Diette, G., Ford, J., Invited Commentary: Attendance and Absence as Markers of Health Status. Am J Epidemiol 2003; 157:870-873.
7. Lewallan, T., Healthy Learning Environments. Association for Supervision and Curriculum Development (ASCD). Infobrief. Number 38. August 2004.
8. Weitzman, M., Klerman, LV., Lamb, G., Menary J., Alpert, JJ., School absence: a problem for the pediatrician. Pediatrics. Volume 69, Issue 6, pp. 739-746, 06/01/1982.
9. Leier JL, Young Cureton V, Canham DL. Special day class teachers' perceptions of the role of the school nurse. J Sch Nurs. 2003 Oct;19(5):294-300.