Abstract
Physical health may be an important variable that influences students’ behavioral and academic performance in school settings. Poor health status is hypothesized to negatively influence student performance even in the presence of evidence-based practices. In this study, teachers reported their perceptions of students’ health status as well as their perceptions of the relation of health status to classroom performance and programming considerations for a sample (N = 217) of elementary and middle school students identified as exhibiting problem behaviors. Results indicated inconsistencies between teachers’ perceptions of student health and school programming considerations. Limitations are presented along with implications for future research and practice.
Being in poor health due to chronic or temporary illness, pain, fatigue, or other physical discomfort likely negatively influences students’ school performance, even in the presence of evidence-based prevention and intervention strategies. Researchers in related disciplines such as medicine, psychology, and education have provided correlational evidence that children’s and adolescents’ generalized physical health, mental health, and problem behavior are highly interrelated. Medical researchers have revealed children and adolescents who suffer from specific physical disorders often have increased problem behavior compared with peers without physical disorders. These results are consistent across children with a variety of chronic illnesses (Lavigne & Faier-Routman, 1992; Silver, Stein, & Bauman, 1999; Wallander, Varni, Babani, Banis, & Wilcox, 1988) and recurrent illnesses (Bussing, Halfon, Benjamin, & Wells, 1995; De Lissovoy, 1963; Hart, Bax, & Jenkins, 1984; Mackner, Sisson, & Crandall, 2004; Trzepacz, Vannatta, Gerhardt, Ramey, & Noll, 2004). Conversely, children and adolescents with the highest ratings of behavior problems also have an increased incidence of health-related problems (Heflinger & Saunders, 2005; Herrenkohl, Herrenkohl, Rupert, Egolf, & Lutx, 1995; Kennedy et al., 2007; Zill & Schoenborn, 1990).
Mental health status also is associated with physical health and behavioral performance in children and youth. Relative to students without mental health or behavioral problems or to those with a single mental health or behavioral problem, students with comorbid concerns have been characterized as having the poorest physical heath (Chavira, Garland, Daley, & Hough, 2010; Combs-Orme, Heflinger, & Simpkins, 2002). Results from numerous studies also have established an association between psychopathology, somatic symptoms and complaints, and problem behavior (Boothroyd & Armstrong, 2005; Borge & Nordhagen, 1995; Campo, Jansen-McWilliams, Comer, & Kelleher, 1999; Domenech-Llaberia et al., 2004; Egger, Angold, & Costello, 1998; Egger, Costello, Erkanli, & Angold, 1999; Last, 1991; Masi, Vavilla, Millepiedi, & Mucci, 2000; Taylor, Szatmari, Boyle, & Offord, 1996; Zuckerman, Stevenson, & Bailey, 1987). Furthermore, researchers in adolescent health have discussed the association between lack of sleep or tiredness and behavioral and emotional problems (see Dahl & Harvey, 2007; Dahl & Lewin, 2002).
From a behavior analytic perspective, a person’s current or day-to-day biological condition may be one of many antecedent variables which influence behavior at any given time. Antecedent events or conditions precede behaviors of interest. To illustrate, Heward and Silvestri (2005) listed several antecedent variables which may influence a student’s performance on a timed math test, including “the amount of sleep the student had the night before” (p. 1136). Physical health likely influences behavior through different functional mechanisms (Carr, 1994; Carr & Smith, 1995; Carr, Smith, Giacin, Whelan, & Pancari, 2003; Conroy & Stichter, 2003). For example, when a student is physically ill and his teacher presents a demand (e.g., behavioral demand or academic task), the demand may be more aversive than usual, and the student may be more motivated to engage in problem behavior to avoid or escape the demand (Carr & Blakeley-Smith, 2006; Carr et al., 2003; Carr & Smith, 1995; Conroy & Stichter, 2003). Alternatively, a student who is physically ill in the presence of an adult in a school setting may be more motivated to engage in problem behaviors to access soothing or comforting attention from the adult (Carr et al., 2003; Carr & Smith, 1995). In each of these hypothetical illustrations, poor physical health as an antecedent event acts as an establishing operation (see Michael, 1982, 1993, 2000) by increasing the momentary effectiveness of a reinforcer (escape from the demand or attention from the adult), thus increasing the frequency of problem behavior.
Behavior analysts have examined physical health as a potential antecedent variable influencing day-to-day behavioral performance of children and adolescents with and without disabilities in school settings. Kennedy and Meyer (1996) observed increases in problem behaviors in a school setting for three adolescents with intellectual disabilities on days when health-related antecedent events occurred (i.e., participants were sleep deprived or displayed allergy symptoms). Ray and Watson (2001) also identified clear patterns of differential responding during functional analyses (FA) for three typically developing preschool students in the presence of a temporally distant antecedent event such as sleep deprivation or bed-wetting during the preceding night. Results from FA varied across the three participants, indicating the influence of health-related antecedent events is likely idiosyncratic to individual students. From these results, Ray and Watson concluded that educational professionals need to consider (a) a variety of events that occur away from school when developing interventions to reduce problem behaviors and (b) the need for increased collaboration between school and home to identify potential antecedent events that influence problem behavior.
Researchers and practitioners working with children and adults with developmental and intellectual disabilities suggest a comprehensive approach to addressing physical health conditions which likely exacerbate problem behavior (Carr & Blakeley-Smith, 2006; Carr et al., 2003; Carr & Smith, 1995; O’Reilly, 1995). For example, Carr and Blakeley-Smith (2006) examined the effects of providing multicomponent, school-based interventions to address health and behavioral concerns for preschool and elementary school students with developmental disabilities. In this study, teachers identified 21 students exhibiting increased problem behaviors on days when they were physically ill. Students then were randomly assigned to one of two conditions. Medical intervention alone (i.e., being sent to nurse, being sent home, and/or recommended to consult pediatrician as needed) was received by 11 students for a period of 10 months. Medical intervention combined with behavioral intervention strategies (i.e., classroom strategies to address students’ escape-maintained problem behavior) was received by 10 students for the 10-month intervention period. Following the intervention period, students who received medical interventions in combination with classroom behavioral interventions were rated by teaching assistants as exhibiting significantly lower levels of the most serious problem behaviors (e.g., aggression, self-injury) and significantly lower levels of less serious problem behaviors (e.g., whining, yelling) compared with students who received medical interventions alone. Teaching assistants also reported students who received medical interventions in combination with behavioral interventions completed significantly more tasks and activities compared with students who received medical interventions alone.
Rationale and Purpose
For many students who exhibit problem behavior, health status is likely an important consideration for purposes of academic and behavioral planning. However, the degree to which teachers consider student health when developing programs for these students is unclear. The purpose of this study was to examine (a) teachers’ reports of student physical health, (b) their perceptions of the influence of student health on academic and behavioral performance in school, and (c) whether teachers consider health when making programming decisions for a sample of elementary and middle school students identified as exhibiting problem behaviors.
Method
Participants and Setting
Students
Teachers provided data for 217 elementary and middle school students participating in a larger, 2-year intervention study. The majority of students were selected for inclusion in the larger study because they were receiving behavior support services in special education (SE) classrooms in 30 elementary schools from three large, urban school districts in Tennessee, Virginia, and Minnesota. The remaining students were selected for inclusion in the larger study because they were rated by their general education (GE) classroom teachers as being at risk of developing emotional or behavioral disorders on the Systematic Screening for Behavior Disorders (SSBD; Walker & Severson, 1991). The current analysis focused on data collected during the follow-up assessment phase of the larger study (i.e., a year after the completion of the 2-year study). A summary of participants’ demographic information is presented in Table 1, including students’ school lunch status (the number of students who paid regular, reduced, or no fee for school lunch; an indicator of socioeconomic status based on families’ reported income). Also, as part of the larger study, researchers conducted student record reviews to gather information about student SE status and support services received. Of the 217 participating students, 118 spent the majority of their school week in self-contained SE classrooms for students who exhibit problem behaviors. For the remaining 99 students, instruction occurred primarily in GE classrooms.
Participant Demographic Summary by Educational Placement. a
Note. IEP = Individualized Education Program; OHI = other health impaired; ADHD = attention-deficit/hyperactivity disorder; ADD = attention-deficit disorder.
Majority of school week spent in setting. bChi-square statistics indicates significant difference (p < .05) in distribution between students who spend majority of the school week in general education classroom settings and students who spend majority of the school week in special education classroom settings.
Teachers
Students’ primary teachers (n = 142) were recruited for this study. These were 57 (40%) special educators, 80 (56%) general educators, 1 (<1%) English language learner teacher, and 4 teachers who did not report placement. Of these teachers, 113 (80%) were female and 24 (17%) were male (missing data for 5 teachers); 78 (55%) were Caucasian, 49 (35%) were African American, 10 (7%) reported ethnicity as “Other,” and 1 (<1%) was Hispanic (4 did not report ethnicity). Regarding levels of education, 53 (37%) reported having bachelor’s degrees, 73 (51%) master’s degrees, 7 (5%) doctoral degrees, and 11 (7%) did not report highest degree earned. Teaching experience ranged from 1 to 40 years with a median of 9 years (M = 11.85, SD = 9.50). Teachers completed the survey for 1 to 6 students: 97 (68%) teachers completed a survey for only 1 student, 27 (19%) for 2 students, 10 (7%) for 3 students, 4 (3%) for 4 students, 1 teacher (<1%) for 5 students; and 3 teachers (2%) completed surveys for 6 students. The median number of surveys completed per teacher was 1 (M = 1.55, SD = 1.04).
Primary Measure
Each participating student’s primary teacher independently completed the Survey of Student Health. Research assistants collected completed surveys, entered data, and conducted data entry reliability assessments to ensure accuracy of data entered.
The Survey of Student Health is a researcher-developed instrument containing 20 items presented in three sections: student health status, relation of health and behavior, and educational programming (see Figure 1). Two features of the survey were modeled after the widely used and referenced Child Health Questionnaire–Parent Form (CHQ-PF50; Landgraf, Abetz, & Ware, 1996). First, similar to instructions for the CHQ-PF50, respondents on the Survey of Student Health were asked to consider the child’s health over the previous 4 weeks. Second, ratings of the frequency of specific health problems were modeled after the CHQ-PF50 question, “During the past 4 weeks, how often has your child had bodily pain or discomfort?” The related response options also were provided: “none of the time, once or twice, a few times, fairly often, very often, and every/almost every day.” The CHQ-PF50 was developed for parents to provide information about their children’s general health: the influence of child health problems on physical and everyday activities, the frequency of children’s bodily pain and discomfort, and ratings of child problem behavior, mood, self-esteem, and other health, academic, or behavioral problems. It was not an appropriate tool for gathering information on teachers’ perceptions of student health, and, more specifically, planning considerations for students; therefore, the Survey of Student Health was developed to address the specific aims of this study.
Survey of Student Health.
A pilot test of the Survey of Student Health was conducted 1 year prior to the survey administration to evaluate usability and structure of the survey and to identify items or areas in need of modification or revision. For the pilot test, 16 teachers enrolled in a university summer course completed the Survey of Student Health for three anonymous and randomly selected students from their classrooms. Teachers were asked to provide comments about the questions posed and the measure in general. Revisions were then made to incorporate relevant feedback and findings.
Teachers’ reports of student health
The first 11 items of the survey consisted of a Likert-type 6-point rating scale, with lower numbers representing fewer complaints or demonstrations of health problems. Teachers were asked to report whether, during the previous 4 weeks, the student either complained about or demonstrated symptoms and characteristics of a variety of health-related problems. Specific ailments included generally feeling ill (e.g., a student saying, “I feel bad”), having a headache, earache, stomachache, sore throat, allergies or common cold (e.g., coughs, sniffles, runny nose, fever), tiredness or lack of sleep (e.g., lethargy, dozing off, yawning), nausea, and asthma (e.g., shortness of breath, wheezing). Possible responses were “none of the time” (1), “one or two times” (2), “a few times” (3), “often” (4), “very often” (5), or “every day or almost every day” (6). These response options were similar to the CHQ-PF50 (Landgraf et al., 1996). Three additional questions elicited teachers’ perceptions about the influence of health on attendance and referrals to the school nurse. Teachers rated how often, in general, students’ illness resulted in (a) a parent or guardian being called during the school day, (b) missing school (as reported by parent or guardian), and (c) being sent to the school nurse or designee. Again, lower ratings indicated fewer absences and nurse visits. In the final item, teachers rated each student’s overall physical health on a scale of 1 to 5 as being “excellent” (1), “good” (2), “average” (3), “somewhat unhealthy” (4), or “very unhealthy” (5). Research assistants instructed teachers to consider physical health that was not related to or characteristic of mental health problems or brain-based symptoms or diagnoses.
Perceived influence of student health on behavior
In this section, teachers were asked to respond to the statement, “On days when this student appears to be sick or not feeling well, there is a noticeable increase in problem behavior.” Possible responses were yes, no, or sometimes. Next, each teacher was asked to indicate agreement with the statement, “In general, this student’s physical health negatively influences his or her academic performance at school.” Scale values were from 1 to 5; possible responses included “strongly disagree” (1), “disagree” (2), “neutral” (3), “agree” (4), and “strongly agree” (5). Similarly, teachers were also asked to indicate their agreement with the statement, “In general, this student’s physical health negatively influences his or her behavioral performance at school.”
Reported educational programming: consideration of student health
In the remaining two items of the survey, teachers were asked, “Is this student’s health considered when planning academic programming?” and “Is this student’s health considered when planning behavioral programming?” Teachers responded to these questions with “yes” or “no”; teachers were instructed to provide an explanation when answering “yes.”
Additional Measure
Teachers’ Report Form (TRF)
Teachers completed the TRF (Achenbach & Rescorla, 2001) for each student participating in the larger study. The TRF was used to assess students’ adaptive functioning, internalizing and externalizing problems, and total problem behaviors. In the present analysis, total scores for students’ Somatic Complaints syndrome were used to supplement the test reliability estimation for the Survey of Student Health. For the Somatic Complaints syndrome profile on the TRF, teachers were asked to describe “physical problems without known medical cause,” including aches or pains, headaches, nausea/feeling sick, eye problems, rashes or skin problems, stomachaches, vomiting/throwing up, and other (on a scale of 0 = not true to 2 = very true or often true).
Results
Test Reliability Estimation
A Cronbach’s alpha coefficient of .88 indicated high internal consistency between survey items for this sample (across all items assessing teachers’ ratings of overall health, the reported frequency of complaints or demonstrations of specific health problems, and teachers’ perceptions of the influence of student health on school behaviors). In addition, the total scores across all items assessing teachers’ ratings of health problems and their influence on school behaviors was correlated with total score ratings for these same students on the Somatic Complaints syndrome profile of the TRF (Achenbach & Rescorla, 2001) with a Spearman’s rank correlation coefficient of .68, p < .001.
Summaries of Teachers’ Responses
Descriptive summaries of teachers’ responses to the Student Health Survey provided information on (a) teachers’ reports of student health, (b) teachers’ perceptions of the influence of student health on school behaviors, and (c) teachers’ reported consideration of student health when planning academic and school programming for the sample of students. Preliminary analyses provided no indication of statistically significant associations between overall ratings of student health and student ethnicity, gender, grade level, or student lunch status.
Preliminary analyses also were conducted to examine the potential associations between ratings for a teacher who completed the Student Health Survey on more than one student (i.e., whether teachers who completed multiple surveys rated all students systematically high or low). A random effects likelihood regression was conducted to estimate variance components (between- and within-class variance) with ratings of health problems and their influence on school behaviors on the Survey of Student Health, clustered by teacher. The resulting low intraclass correlation of .21 indicates a low correlation between health ratings for students rated by the same teacher; therefore, clustering of student health ratings by teacher was not considered in subsequent analyses.
Teachers’ reports of student health
The vast majority of students (n = 196; 90%) in the full sample were rated as having excellent to average overall health (M = 2.26, SD = .93 using a 5-point scale). However, students who spent the majority of their school week in GE classroom placements were rated as having slightly better health than students who spent the majority of their school week in SE placements, χ2(1, N = 217) = 14.93, p = .005. Of the 99 students placed primarily in GE classrooms, teacher ratings indicated 29% (n = 29) had “excellent health,” 47% (n = 46) “good health,” 15% (n = 15) “average health,” 8% (n = 8) were “somewhat unhealthy,” and 1% (n = 1) was “very unhealthy.” Of the 118 students placed primarily in SE classrooms, approximately 14% (n = 16) were rated as having “excellent health,” approximately 41% (n = 49) good health,” 35% (n = 41) average health,” 8% (n = 10) were rated as being “somewhat unhealthy,” and 2% (n = 2) as “very unhealthy.”
Teachers reported that 88% (n = 87) of students placed primarily in GE settings and 75% (n = 88) placed primarily in SE classrooms complained about their health (e.g., “I feel bad” or “I don’t feel well”) “none of the time” or “one or two times” over the previous 4 weeks. Teachers reported that 10% (n = 10) of students placed primarily in GE classrooms and 14% (n = 17) of students primarily placed in SE classrooms complained about their health a “few times” during the previous 4 weeks. Only 2% (n = 2) placed primarily in GE classrooms complained about their health “often,” “very often,” or “every day or almost every day” over the previous 4 weeks whereas 11% (n = 13) placed primarily in SE classrooms complained about their health “often,” “very often,” or “every day or almost every day.” Comparisons between students in GE and SE placements were not significant at the .05 level, χ2(1, N = 217) = 10.36, p = .066.
A summary of the types of illnesses reported is presented in Table 2. In this sample, the most frequently reported health problem was symptoms related to fatigue. Almost a fourth of the full sample (n = 53, 24%) was reported to complain about or demonstrate characteristics of lack of sleep or being tired during the previous 4 weeks “often,” “very often,” “every day or almost every day.” A higher percentage of students placed primarily in SE classrooms (n = 36, 30%) were reported to often complain about or demonstrate characteristics of lack of sleep, compared with students who spent the majority of the week in GE placements (n = 17, 17%), χ2(1, N = 217) = 5.19, p = .023.
Students’ Complaints and Demonstrations of Health Problems (N = 217).
Percentage of students who were reported to have complained or demonstrated the health problem at each level of frequency over the previous 4 weeks. bComplained about symptom(s). cDemonstrated symptom(s). dChi-square statistics indicates significant difference (p < .05) in distribution between students who spend majority of time in general education classroom settings and students who spend majority of time in special education classroom settings. eComplained about and/or demonstrated symptom(s).
Among students, 21% (n = 21) primarily placed in GE classrooms and 36% (n = 43) primarily placed in SE classrooms were reported to frequently complain about or demonstrate symptoms associated with at least one health problem (i.e., headaches, earaches, stomachaches, sore throat, allergies or the common cold, lack of sleep or being tired, nausea, or asthma). In addition, multiple health problems were rated as frequently problematic for 4% of the students (n = 4) who spent the majority of their school week in GE classrooms: 3 students were reported to exhibit two health problems while 1 student was reported to exhibit three health problems. In contrast, 14% of students (n = 17) who spent the majority of their school week in SE classrooms were rated by their teachers to frequently complain about or demonstrate symptoms associated with multiple health problems: 10 students were reported to exhibit two health problems, 3 students were reported to exhibit three health problems, and 4 students were reported to exhibit four health problems.
Teachers rated only 10 students (n = 5 [5%] GE and n = 5, [3%] SE) as “often” or “very often missing” school because they were sick (as reported by parents or guardians). Parents or guardians often were called due to illness for 4 students (n = 1 [1%] GE and n = 3 [2%] SE). Five students (n = 3 [3%] GE and n = 2 [2%] SE) were reported to be “often” or “very often” sent to the school nurse or designee. Comparisons between students in GE and SE placements were not statistically significant.
Perceived influence of student health on school behavior
For over a third of the sample, teachers reported that an increase in problem behavior was “noticeable” on days when the student appeared to be feeling unwell (n = 13 [13%] GE and n = 17 [14%] SE) or “sometimes noticeable” (n = 18 [18%] GE and n = 37 [31%] SE). Teachers “agreed” or “strongly agreed” physical health negatively affected: academic performance for 9% of students (n = 9) in GE primary placements and for 12% of students (n = 14) in SE primary placements; behavioral performance for 11% of students (n = 11) in GE primary placements and for 16% of students (n = 19) in SE primary placements; and both academic and behavioral performance for 8% of students (n = 8) from GE primary placements and for 10% of students (n = 12) from SE primary placements. Comparisons between students in GE and SE placements were not statistically significant. Of the 33 students from the full sample whose health was reported to negatively influence either academic or behavioral school performance, approximately 67% (n = 22) were reported to have symptoms of fatigue “often” (n = 14), “very often” (n = 2), “every day or almost every day” (n = 6).
Reported Consideration of Student Health in Educational Programming
Academic modifications reported
Teachers of students who spent the majority of their school week in GE placements reported student health was considered when planning academic programming for 8% of students (n = 8). Of those eight students, teachers provided explanations of these types of considerations for six students, citing antecedent modifications to curriculum, instruction, and assignments. Teachers’ comments included “I constantly plan for the students to be moving around [keep her awake],” “prompts him to stay on task, extra time to complete assignments,” “determine if extra time is needed for work to be done,” “plan to change activities often and to have students move physically,” and “plan around [the student’s] pull-out schedule.” One teacher mentioned “IEP goals” (Individualized Education Plan) when explaining how student health was considered when planning academic programming for 1 student who was primarily in a GE placement.
Teachers of students who spent the majority of their school week in SE placements reported student health was considered when planning academic programming for 25% of students (n = 30). Of those 30 students, teachers provided explanations of such considerations for 18 students. Specific explanations included antecedent modifications to curriculum, instruction, and assignments for 4 students (e.g., “modify work” and “flexible curriculum”); references to the student’s IEP were made for 5 students (e.g., “IEP requires consideration” and “IEP goals”); references to a student’s specific disability and its influence on learning were made for 4 students; and references to medication and communication with parents were provided for 2 students. For 1 student, a teacher reported it was important to “listen to concerns, offer help if I can; [this student] often just wants attention” and another teacher reported, “[the student’s] somatic complaints are generally emotional in nature/origin; during periods of emotional disturbance, she requires 1:1 instruction.” One teacher reported a student was in normal health, which was considered when planning his academic programming.
Behavioral modifications reported
Teachers reported considering student health when planning behavioral programming for 10% of students (n = 10) who spent the majority of their school week in GE placements. Here, teachers provided explanations of considerations for seven students. Teachers’ specific explanations included “try to ignore irritability,” “determining how bad the behavior is,” making antecedent adjustments such as accommodations when the schedule changes, “having tissue in her pocket to decrease getting up and down,” frequently changing or moving seats, and a general consideration of IEP goals.
Teachers also reported considering student health when planning behavioral programming for 26% of students (n = 31) who spent the majority of their school week in SE placements. Teachers provided explanations of considerations for 21 students. Teachers’ explanations included antecedent modifications or considerations to curriculum, instruction, and assignments for 5 students (e.g., flexible schedule, general modifications, “rest time, less work”), general references to a student’s IEP or disability for 7 students, general references to behavioral interventions or strategies for 2 students (e.g., “flexible social skills training” and “it is noted that she has pseudoseizures for attention. These must not be treated as real until known to be false”); references to communicating with parents or students’ medication for 5 students; and references to 2 students’ emotional well-being (e.g., “parent and doctor [are] exploring possibility of anxiety/depression” and consideration of somatic complaints and provision of 1:1 instruction during “periods of emotional disturbance”).
Modifications for students whose health influences school performance
Teachers indicated student health was considered when planning academic programming for approximately half of the students whose teachers reported health negatively influences academic performance (4 of 9 students placed primarily in GE classrooms and 8 of the 14 students placed primarily in SE classrooms). Teachers similarly indicated student health was considered when planning behavioral programming for approximately half of the students whose teachers reported health negatively influences behavioral performance (4 of 9 students primarily in GE classrooms and 8 of the 14 students primarily in SE classrooms).
Discussion
The purposes of this study were to examine teachers’ reports of student physical health for a sample of elementary and middle school students identified as exhibiting problem behaviors, to examine teachers’ perceptions of the relation between health and performance, and to examine teachers’ reported considerations of health issues when planning academic and behavioral programming. Much of the existing literature on the relation between student health and school behavior has focused on students with moderate to severe developmental and intellectual disabilities. The findings of this study extend that literature to a larger population of students with and without disabilities in several ways.
First, teachers reported good physical health for the vast majority of this sample of children identified as exhibiting problem behavior in school, though students who spent the majority of their time in SE placements were rated as having slightly poorer health compared with students who spent the majority of their time in GE placements. Teachers reported slightly less than one third of these students often complained about or demonstrated symptoms associated with at least one health problem. Interestingly, the majority of these students’ reported health problems were related to lack of sleep or being tired with a higher percentage of students in SE placements reported to often complain about or demonstrate characteristics of lack of sleep.
Second, results provide further support that poor physical health or not feeling well may influence students’ day-to-day behavior. For more than one third of the students, teachers reported a noticeable increase in problem behaviors at least some of the time when the student appeared to be feeling unwell. Teachers also reported that for approximately 15% of students, physical health status negatively influenced either academic or behavioral performance at school. Of the students whose health was rated to negatively influence academic or behavioral performance at school, approximately 67% were reported to complain about or demonstrate symptoms related to lack of sleep.
Third, despite teachers’ perceptions about the negative influence of student health on students’ school performance, teachers provided little indication that school professionals developed comprehensive, multicomponent intervention strategies to appropriately address the influence of health on problem behaviors. Specifically, teachers indicated considering student health when planning school programs for fewer than half of the students whose health was reported to negatively influence their school performance. Teachers primarily provided explanations of modifications to curriculum, instruction, and assignments and general references to students’ IEPs. Teachers did not specify how the modifications were selected (e.g., whether modifications were linked to specific health concerns, whether medical professionals were consulted), or whether they were effective in decreasing problem behavior.
Fourth, results indicate no consistent use of medical attention or medical information to address students’ physical health. For example, while 21 students in this sample were reported to be somewhat or very unhealthy, only 5 students in this sample were reported to be sent to the school nurse or designee on a frequent basis. Teachers mentioned communicating with parents regarding student health for only 4 students. These findings suggest teachers, parents, and health service providers engaged in little collaboration to address student health problems.
Limitations
These findings are based only on teachers’ responses to the brief Survey of Student Health. Teachers were not required to provide detailed information about each student’s idiosyncratic symptoms, what led the teacher to perceive the student to be in poor health, and how the student’s health specifically influenced school performance. Teachers were only asked whether or not (i.e., “yes” or “no”) student health was considered for academic and behavioral programming; this does not provide adequate information about the degree to which each student’s health was considered when making programming decisions. More detailed information is needed, particularly for students whose poor health influences school performance. In addition, although TRF ratings were consistent with survey results, teacher reports were not verified by multiple informants or information sources (e.g., collecting information from parents, school nurses, or family physicians or conducting detailed examinations of students’ IEPs of behavior support plans), and student medical records were not evaluated to confirm or examine further medical diagnoses or symptomology.
Although researchers instructed teachers to consider physical health that was not related to mental health problems or brain-based symptoms or diagnoses, teachers’ adherence to this instruction was not monitored. Whether students’ complaints or demonstrations of symptoms were primarily associated with physical or mental concerns remains unknown. The results of this study do not adequately address the interrelatedness of mental health and physical health and their combined influence on school performance. Furthermore, researchers did not assess test–retest stability with a portion of the responding teachers; this would have provided further evidence of the reliability of the measure.
Implications for Research and Practice
For some students, ongoing consideration of student health may be needed to develop successful and efficient strategies and programs to prevent and reduce problem behaviors. Researchers should continue to examine more detailed information about student health and its relation to school performance and to replicate earlier experimental studies for participants with mild to moderate disabilities or students without disabilities who have health problems and exhibit problem behaviors in a variety of school settings (e.g., students primarily placed in SE or GE classrooms). FA should include examinations of the influence of health-related antecedent conditions on problem behaviors maintained by attention (e.g., from teachers or peers) and escape (e.g., from academic demands) for this population of students. Researchers should conduct experimental analyses of multicomponent intervention strategies that are easily implemented in classroom and school settings and are appropriately selected to address students’ health concerns and behavioral concerns. In practice, this would require school and medical professionals to collaborate with parents to identify health-related antecedent conditions that exacerbate problem behaviors in school.
In this sample, complications and demonstrations of symptoms related to lack of sleep were the most frequently reported health problems. Symptoms of fatigue were reported for 67% of students whose teachers reported health negatively influenced school performance. This association should be examined further for similar student populations in an effort to identify and implement effective comprehensive medical and behavioral interventions to mitigate the influence of lack of sleep on school behavior. This area of research would benefit from combined expertise across disciplines; specifically, expertise in behavior analysis and interventions and expertise in medical and mental health etiology and intervention.
Finally, researchers should continue to explore ways to promote teachers’ and other professionals’ appropriate and thorough consideration of student health when planning behavioral and academic programs. Future research should examine factors that influence whether teachers consider health, the degree and quality of collaboration with other professionals in and out of schools and barriers to such collaboration, and what informs their programming decisions as well as the appropriateness of those decisions.
Footnotes
Authors’ Note
The opinions expressed in this article are those of the authors and do not necessarily reflect those of the funding agencies.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research and preparation of this manuscript was supported in part by the Institute of Educational Sciences grant (H324P040013), the Office of Special Education Programs Leadership Training grant (H325D020022), and Vanderbilt’s Experimental Education Research Training grant (R305B040110).