Toolkit for Addressing Health-Related Causes of Chronic Absenteeism

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action

Taking action to address health-related chronic absenteeism can have a powerful impact on students’ academic success and well-being for a lifetime.

This document highlights key points from Healthy Schools Campaign’s toolkit for addressing this critical issue. It focuses on preparing educators—particularly school district decision-makers —with knowledge and practical guidance for creating meaningful change to address health-related chronic absenteeism.

To access the full toolkit, please visit: healthyschoolscampaign.org/chronic-absenteeism

EVERY CHILD DESERVES TO LEARN + THRIVE healthyschoolscampaign.org/chronic-absenteeism · 1 Chronic Absenteeism and Student Health

Chronic absenteeism—or missing 10 percent or What Is the Impact of Chronic Absenteeism? more of school days for any reason, excused or Frequent absences can be devastating for a child’s unexcused—detracts from learning and is a proven school success. Consider, for example: early warning sign of academic risk and school dropout. · Children who are chronically absent in both Even the most thoughtful efforts to reduce dropout kindergarten and first grade are much less likely to be rates, address the achievement gap and ensure all reading at grade level by third grade. students receive a quality education are threatened by the problem of chronic absenteeism. Nationwide, a · Students who are not reading at grade level by the staggering number of children are chronically absent, third grade are four times more likely to drop out of often at a very young age and often without attracting high school. attention or intervention. · By sixth grade, chronic absenteeism becomes one of the leading indicators that a student will drop out of While the causes of chronic absenteeism are multi- high school. fold, one stands out as especially significant: student health. The crisis of health-related chronic absenteeism · By high school, attendance is a better dropout is especially poignant as it primarily affects young indicator than test scores. children in ways that can shape academic outcomes for · A student who is chronically absent for any year their entire school career. between eighth and twelfth grade is over seven times more likely to drop out. The connection between student health and chronic absenteeism is clear and direct. Both chronic and Chronic absenteeism at a young age is a powerful acute health conditions can prevent students from factor in educational attainment, which affects not only attending school. Research indicates that common adult success but also adult health outcomes. health conditions resulting in missed school include asthma, influenza, diabetes, obesity and related illness, Intervention to prevent and address health-related seizure disorders, mental health and anxiety and vision chronic absenteeism can have a tremendous impact on problems. This pattern may be either exacerbated students’ achievement at school and on their lifelong or ameliorated by a variety of factors in the school wellness. Addressing this issue in a successful and environment. holistic way involves a multi-faceted approach that includes effective policy, programs and partnerships.

1 · Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action Who Is Most Affected by Health-Related Chronic Learn More in the Full Report Absenteeism? Visit healthyschoolscampaign.org/chronic-absenteeism to While health-related chronic absenteeism can affect download the Understanding Chronic Absenteeism chapter students of any background, its most devastating and Connecting Chronic Absenteeism and Student Health impact is felt by students who face health disparities, section for more detail, case studies and content addressing: poverty and other challenges in attaining school success. · What Causes Chronic Absenteeism? · What Health Conditions Contribute to Chronic Compounding the problem, health-related chronic Absenteeism? absenteeism rates are disproportionately high among · What Is the Impact of Health Factors in the School students who benefit most from being in school: Environment? students who are raised in poverty, face significant health disparities and in many cases do not have access to resources that would allow them to catch up. In this context, addressing health-related chronic absenteeism is a key factor in closing the achievement gap and supporting learning for all students.

The Health-Learning Connection Educators intuitively recognize that healthy students Dr. Basch points out that if health problems compromise are better prepared to learn, and the past decade has students’ motivation and ability to learn—as seen in brought an abundance of research documenting the part through whether they are well enough to attend impact of health on academic achievement. school—educational efforts such as teacher preparation, financing and curriculum are jeopardized. In particular, Dr. Charles Basch of Columbia University Teachers College has pioneered research documenting In this context, addressing health-related chronic the ways educationally-relevant health disparities absenteeism is a key factor in closing the achievement contribute to the minority achievement gap. Chronic gap and supporting learning for all students. absence is one of the most visible and profound ways this connection manifests itself.

healthyschoolscampaign.org/chronic-absenteeism · 2 Understanding Student Health Needs

Students are absent for many different reasons, and Key Data Sources no two communities are alike. Even more so than Key sources of public data can shed light on the issues with other issues, it is important to identify what is affecting students and their health. These sources of happening in your community and tailor your strategy data include: to address the factors that are having the biggest · School health information cards impact on student attendance. · Public health data systems This understanding can play an important role in · Hospital community health needs assessments informing the types of services and programs you and your partners implement in schools and in the · County health rankings community to support better attendance. This review · Youth Risk Behavior Survey of health needs can focus on the prevalence of health · State-level surveys conditions such as childhood asthma and tooth decay. It is also critical to consider social, economic and Once you have developed a better understanding of environmental factors in the community and school— student health needs, this information can be used to such as levels of air pollution, rates of violent crime, inform the services and programs that are implemented housing trends and more—to understand the full scope to address chronic absenteeism. of children’s health needs within your community and intervene accordingly.

Learn More in the Full Report Visit healthyschoolscampaign.org/chronic-absenteeism to download the Understanding Student Health Needs section for more detail about each of these key data sources.

3 · Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action Addressing the Health-Related Reasons Students Are Absent

While many issues contribute to health-related chronic · School-based behavioral health services absenteeism, several conditions have an especially · Positive behavioral interventions and supports significant impact and therefore represent practical · Wraparound services opportunities for positive change: asthma, oral health, behavioral health, food insecurity and acute illness. · Trauma sensitive schools These conditions have high prevalence among children, · Social and emotional learning disproportionately affect children of color and have · Staff self-care a direct impact on student attendance. Research identifies proven or promising school-based programs Food Insecurity and Related Conditions to address each of these health conditions. Food insecurity and related conditions such as obesity are closely linked to absenteeism in multiple ways. Best Asthma practices and proven interventions include: Asthma is one of the leading causes of school absenteeism, accounting for one-third of all days · Universal school breakfast programs of missed instruction. Best practices and proven · Backpack programs interventions include: · School pantry programs · Comprehensive asthma management programs · High quality physical activity programs · Programs teaching children how to manage their own asthma Acute Illness Acute illnesses, such as influenza, strep throat or · Healthy indoor air quality in your school ear infections, have a direct and significant impact · Green cleaning at school on attendance. Roughly 40 percent of school-aged children missed three or more days of school in the past Oral Health year due to acute illness. Best practices and proven Children age 5-17 miss nearly two million school days interventions include: in a single year due to dental health problems. Best practices and proven interventions include community- · Green cleaning at school based oral health programs, including: · Handwashing education and support · Dental screening · Influenza vaccine awareness campaign · Dental sealants Learn More in the Full Report · Dental preventive services Visit healthyschoolscampaign.org/chronic-absenteeism to · Basic preventive and restorative dental services download the Strategies for Addressing Common Health Causes of Absenteeism section for more detail about each Behavioral Health of these causes, including: When students’ behavioral health needs are met, they are less likely to be absent and more likely to · Data on prevalence, disparities and connection to be engaged in and have a sense of connectedness to learning school. A total of 13–20 percent of children experience · Best practices and proven interventions a behavioral health disorder in a given year. Best · Key partners to help address the issue practices and proven interventions include: · Case studies spotlighting a successful approach

healthyschoolscampaign.org/chronic-absenteeism · 4 Building Effective Partnerships to Support Student Health

While many school leaders recognize the importance · Local community benefits experts—this could be of healthy school environments for addressing chronic the individual responsible for overseeing community absenteeism, the scale of the work ahead can seem benefits or community outreach at one of the local, daunting—especially in the context of widespread non-profit children’s hospitals budget cuts and a lack of resources for supporting · Community organizations dedicated to supporting health and wellness. However, schools do not need to children’s health take on this great challenge alone. Health and public · State or local advocacy organizations health sectors can play a key role in supporting efforts to address chronic absenteeism. · Public health agencies or public health departments · Pediatricians, and the local chapter of the American Partners in the health and public health sectors are Academy of Pediatrics well-positioned to support schools in addressing the health-related causes of chronic absenteeism. This may These partners will vary greatly by community; range from technical assistance to funding for health the most practical partnerships will emerge from services and many areas in between. Such partnerships the primary causes of chronic absenteeism and represent a rapidly evolving area where communities opportunities for change identified in your school nationwide are finding innovative ways to collaborate community. around shared goals for children’s health. Learn More in the Full Report Who Are Key Partners in the Health and Public Visit healthyschoolscampaign.org/chronic-absenteeism to Health Sectors? Possible partners include: download the Key Partnerships section for more detail, plus case studies and content addressing: · Local hospitals, particularly children’s hospitals · Why is the health sector motivated to address chronic · Accountable Care Organizations, Managed Care absenteeism? Organizations and health plans responsible for · What are key opportunities for collaboration? providing coverage to students in your community

5 · Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action Building Your Capacity

Once you decide to implement an effort to reduce Ensuring Sustainability chronic absenteeism, it is critical to generate support and Ensuring the sustainability of efforts to address chronic build your long-term capacity to engage in this work. absenteeism is key to their success. Key strategies for supporting sustainability include cross-sector This summary briefly highlights several key supports; collaboration; multi-sector data and accountability please see the full report for detail about each. systems; multiple funding sources; and increased access to resources through Medicaid. Key Partners and Resources Many partners and resources are available to support Learn More in the Full Report this effort, including specialized instructional support Visit healthyschoolscampaign.org/chronic-absenteeism to personnel; school-based health centers and community download the Building Your Capacity section for more detail clinics; public health agencies; local hospitals and health about each of these resources. providers; community organizations; state education agencies; Attendance Works; the U.S. Department of Education; and regional offices of the EPA and USDA.

About Healthy Schools Campaign Healthy Schools Campaign (HSC) is dedicated to for America’s Health, HSC co-convenes the National making schools healthier places where all children can Collaborative on Education and Health, which is working learn and thrive. HSC advocates for children to have to transform the conditions of health in schools across access to nutritious school food, physical activity, school the country and has a key focus on chronic absenteeism. health resources, green schoolyards and clean air. HSC has a special focus on the wellness and environmental Acknowledgements health issues affecting low-income students of color. Special thanks to members of the National Collaborative We start with a social justice perspective and believe on Education and Health Working Group on Chronic this focus is especially critical in light of the vast health Absenteeism for their work that created the foundation disparities our nation faces. HSC facilitates collaboration for this toolkit, to Trust for America’s Health for their among parents, educators, students and policymakers partnership in convening the National Collaborative on to help prepare this diverse group of stakeholders to Education and Health and to Attendance Works for their lead change for healthier schools at the school, district, thoughtful review and for their leadership and vision on state and national levels. In partnership with Trust the issue of chronic absenteeism.

healthyschoolscampaign.org/chronic-absenteeism · 6 Background: Chronic Absenteeism + Student Health

Section One

This section provides a foundation for understanding and acting to address health-related chronic absenteeism.

EVERY CHILD DESERVES TO LEARN + THRIVE What Is Chronic Absenteeism? Understanding In many ways, absenteeism is a simple issue: when students miss school, they miss opportunities to learn. Chronic Absenteeism At the same time, the issue reveals a complex set of An Introduction social, physical and environmental factors at a variety Chronic absenteeism—or missing 10 percent or of levels. Many of these factors relate to health. This more of school days for any reason, excused or section outlines a foundation for connecting the many unexcused—detracts from learning and is a proven factors that shape chronic absenteeism and efforts to early warning sign of academic risk and school dropout. address it. Even the most thoughtful efforts to reduce dropout For the purpose of this toolkit, chronic absenteeism is rates, address the achievement gap and ensure all defined as missing 10 percent or more of school days students receive a quality education are threatened in a school year for any reason, including both excused by the problem of chronic absenteeism. Nationwide, a and unexcused absences. A school’s chronic absence staggering number of children are chronically absent, rate is the percentage of students who are chronically often at a very young age and often without attracting absent. attention or intervention. The use of a percentage rather than number of days Chronic absenteeism isn’t just a matter of truancy or promotes earlier identification of students at risk skipping school. In fact, many of these absences are for chronic absence to trigger intervention. Using a excused and tied directly to health factors. percentage allows for the identification of students A snapshot of the current environment shows: who are on track for chronic absence at any point during the school year even if a student only misses · 5 million to 7.5 million students across the U.S. miss two or three days each month. Attendance Works, a nearly a month of school each year. leading authority on policy and practice supporting · Children who are chronically absent in both school attendance, recommends using this definition of kindergarten and first grade are much less likely to be chronic absenteeism. reading at grade level by third grade; students who Truancy and school absenteeism have been issues in are not reading at grade level by third grade are four the U.S. since the introduction of compulsory education times more likely to drop out of high school. and mandatory attendance. Every state requires that · Rates of chronic absenteeism are highest among children attend school or participate in an equivalent students from low-income families, communities of such as home schooling. However, truancy and chronic color and those with disabilities. These groups are absence are not the same. Truancy focuses only on disproportionately affected by high rates of illness. unexcused absences; looking at only these absences will underestimate the total potential school time lost Compounding the problem, health-related chronic to absenteeism. A focus only on truancy by definition absenteeism rates are disproportionately high among overlooks the impact of chronic absence on students students who benefit most from being in school: who miss school as a result of health problems. students who are raised in poverty, face significant health disparities and in many cases do not have access In addition, it is important to note that a school can to resources that would allow them to catch up. In this have a chronic absenteeism problem despite high context, addressing health-related chronic absenteeism average daily attendance. Schools and districts that is a key factor in closing the achievement gap and have high average daily attendance numbers often supporting learning for all students. overlook the chronically absent students because they are hidden in the average daily attendance data. This section provides an overview of the scope and For example, in a school with 200 students and a 95 impact of the challenge we face and the myriad ways percent average daily attendance rate, 60 students (or chronic absenteeism intersects with health.

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 1 30 percent) could miss an entire month of school over While it may be difficult to isolate the leading causes the course of the school year. Aggregate data do not of chronic absenteeism in a given community, research reveal whether more students are missing a few days clearly shows that health issues are a primary cause of or whether a small but significant minority of students chronic absenteeism across communities and across experience excessive absences. the nation. Understanding and addressing the health- related factors surrounding chronic absenteeism is a What Causes Chronic Absenteeism? proven strategy for supporting attendance and learning. Attendance is connected to multiple physical, social and environmental factors at the individual, family, What Is the Impact of Chronic Absenteeism? community, school and district levels. Students miss Frequent absences can be devastating for a child’s school for a variety of reasons that researchers group school success. Consider, for example: into three categories: · Children who are chronically absent in both · Barriers: Students cannot attend school because of kindergarten and first grade are much less likely to be barriers. Examples include unmanaged chronic health reading at grade level by third grade. conditions (for example, asthma), homelessness or a · Students who are not reading at grade level by third lack of transportation. grade are four times more likely to drop out of high · Aversions: Students will not attend school because of school. feelings of aversion. These feelings can be related to · By sixth grade, chronic absenteeism becomes one of mental health conditions, bullying, a negative school the leading indicators that a student will drop out of climate, overly punitive discipline policies or even lack high school. of engaging instruction. · By high school, attendance is a better dropout · Myths: Students do not attend school because indicator than test scores. families are unaware of how absences, even excused, · A student who is chronically absent for any year can add up to too much time lost in the classroom, between eighth and twelfth grade is over seven times especially in the early years. This can also relate to more likely to drop out. misunderstandings or fear surrounding health-related issues such as lice. Educational achievement is not only a predictor of adult success; it also strongly predicts adult health outcomes. Children miss school for many different reasons, and Students who do not graduate from high school have every community is unique in the physical, social and greater health risks as adults than those who complete environmental circumstances that students face. No high school.The less education adults have, the more one strategy can address all attendance issues. likely they are to smoke, be overweight, have diabetes School districts generally do not systematically collect and die prematurely of certain chronic conditions. For information about why students are absent from educators seeking to improve attendance and academic school, making it challenging to determine which achievement, this connection to long-term health reasons are the most significant in which community. outcomes is particularly relevant in that it highlights a Even when schools do ask why a student is absent, clear incentive for the health sector and public health the information given by students or parents may sectors to support efforts to address the health-related mask other underlying issues. The U.S. Department causes of chronic absenteeism. of Education’s Office for Civil Rights requires school Educational achievement is also strongly related to districts to report rates of chronic absence in the pathways out of poverty. One of the most effective biennial Civil Rights Data Collection but does not strategies for providing pathways out of poverty is require information about the reasons. to support strong attendance and address causes of absenteeism.

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 2 between 5 and 17 years old miss nearly two million Connecting Chronic school days in a single year nationwide due to dental health problems. Tooth decay and dental pain are Absenteeism and easily treatable if students have access to dental care; Student Health the consequences of leaving such pain untreated are significant not only for children’s lifetime health, While the causes of chronic absenteeism are multi- but also for their education. Schools can take on this fold, one stands out as especially significant: student issue by partnering with public health and health health. The crisis of health-related chronic absenteeism providers to increase access to dental services. is especially poignant as it primarily affects young Innovative models such as teledentistry show great children in ways that can shape academic outcomes for promise in this area. their entire school careers. · Behavioral health. Thirteen to 20 percent of What Health Conditions Contribute to Chronic children experience a behavioral health disorder in Absenteeism? a given year. Despite the prevalence of behavioral The connection between student health and chronic health disorders among children, only 25 percent of absenteeism is clear. Both chronic and acute health children in need of behavioral health care get the conditions can prevent students from attending school. help they need. When students’ behavioral health Research indicates that common health conditions needs are not met, they are more likely to be absent resulting in missed school include asthma, influenza, and less likely to be engaged in and have a sense diabetes, obesity and related illness, seizure disorders, of connectedness to school. For example, children mental health and anxiety and vision problems. This affected by ADHD are more likely to exhibit tardiness pattern may be either exacerbated or ameliorated by a and absenteeism. In addition, reduction of alcohol variety of factors in the school environment. and substance misuse among youth is associated with better attendance rates. The examples below highlight the scale of this problem. · Violence and trauma. Twenty percent of children These examples were chosen because they have high witnessed violence in their family or in the prevalence among children, have a direct link to student neighborhood during the previous year. In addition, attendance and have proven school-based strategies 16.6 percent of children experience physical for addressing them. abuse, 9.3 percent experience sexual abuse and 7.1 · Asthma. Nearly one in 10 children (9.9 percent) percent experience emotional/psychological abuse. age 4-14 are diagnosed with asthma.Asthma is a Violence and trauma can affect children’s ability and leading cause of school absenteeism, accounting for willingness to attend school. As is described above, one-third of all days of missed instruction. Children only 25 percent of children in need of behavioral with persistent asthma are more than three times health services get the help they need which has as likely to have 10 or more absences than their significant implications for children impacted by peers. Asthma can be exacerbated by factors in the violence and trauma. school environment, particularly issues such as mold · Acute illness. Acute illnesses, such as influenza or or harsh cleaning chemicals that affect indoor air strep throat, also impact attendance. Roughly 40 quality. Yet it doesn’t have to be this way: research percent of school-aged children missed three or more has shown that creating healthy indoor environments days of school in the past year due to acute illness. A and providing adequate levels of school nursing can study in Central Texas led by E3 Alliance found that all but eliminate the disparity in attendance between 48 percent of the absences in nine schools across students with asthma and their peers. two school districts were due to acute illness. · Oral health. A full twenty percent of children age 5-11 have at least one untreated decayed tooth. Children

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 3 Of course, causes of health-related chronic absence for missed instruction and the other missed benefits of extend far beyond these few issues. Students may also being in school, such as access to nutrition programs be chronically absent because of a wide range of other and services. health issues ranging from flu to vision problems to In many cases, these same students attend schools pregnancy. Other health-related factors such as hunger, that lack resources to provide the health-promoting housing insecurity, substance abuse and violence in the conditions shown to support attendance and lifelong community also play a significant role. For more detail, wellness. Students in low-income schools, for example, see Healthy Schools Campaign’s overview of leading are less likely to have recess and high-quality physical health conditions affecting student attendance. education than students in higher-income schools. Who Is Most Affected by Health-Related Chronic In addition, schools serving low-income communities Absenteeism? are more likely to have no school nurse or to have While health-related chronic absenteeism can affect higher ratios of students to nurses than schools serving students of any background, its most devastating higher-income communities. impact is felt by students who face health disparities, poverty and other challenges in attaining school Educators intuitively recognize that healthy students success. Research shows that these are the same are better prepared to learn, and the past decade students who benefit most from being in school. has brought an abundance of research documenting the impact of health on academic achievement. In This impact is driven by two related factors: higher particular, Dr. Charles Basch of Columbia University rates of health-related chronic absence, and a more Teachers College has pioneered research documenting profound impact of that absence. Students who face the ways educationally-relevant health disparities disproportionate rates of illness or other factors contribute to the minority achievement gap. Chronic known to cause chronic absence (such as a lack of absence is one of the most visible and profound ways transportation) often also lack resources to make up this connection manifests itself.

Who Is Most at Risk for Chronic Absenteeism? In 2015, Healthy Schools Campaign and Attendance Children of color: The highest absenteeism rates Works published Mapping the Early Attendance Gap, nationwide were among American Indian/Alaskan a report that explores the attendance gap using data Native students in both 4th and 8th grade. Black from national sources and the National Assessment of and Hispanic students typically have higher levels of Educational Progress (NAEP). The data identify several absenteeism than white students, with wide gaps in groups of students most at risk for chronic absence: some states. Children of color face higher rates of health disparities, are more likely to suffer from asthma and Low-income children: 23 percent of low-income 4th are more likely to go to the emergency room to deal with graders missed three or more days in the month illness. prior to the data collection, compared to 17 percent of their peers. In 8th grade, the gap was 8 points Children with disabilities: 25 percent of 4th graders and with significantly higher rates in some states. Weak 27 percent of 8th graders who identified as needing attendance often reflects the challenges that accompany support for disabilities reported high absenteeism poverty, such as unreliable transportation, unstable compared to 19 percent of others in both grades. Some housing and little access to health care. In addition, of these absences result from the health concerns students in neighborhoods of concentrated poverty are of students with physical disabilities. Others reflect less likely to attend a school with a nurse or health clinic, bullying, lack of appropriate educational placements and are more likely to face safety concerns at school or and school aversion, which often affect students with on the way to school. learning disabilities.

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 4 Dr. Basch points out that if health problems during school hours. In addition, a literature review by compromise students’ motivation and ability to learn the American Public Health Association found that —as seen in part through whether they are well enough access to a school-based health center was associated to attend school—educational efforts such as teacher with increased student attendance and that African preparation, financing and curriculum are jeopardized. American males who used a school-based health center were three times more likely to stay in school In this context, addressing health-related chronic than those who did not use a school-based health absenteeism is a key factor in closing the achievement center. Dental health, which sometimes falls outside the gap and supporting learning for all students. public dialogue on “health” issues, is especially worth noting as a key area for focus in school health efforts What Is the Impact of the School Environment? One critical strategy for addressing health-related aimed at reducing chronic absenteeism. Successful chronic absenteeism is ensuring that children are able school-based programs treating dental health include to attend school in healthy school environments. school-based sealant programs and mobile dental clinics. Many students, including groups most at risk for health-related chronic absenteeism, do not have access Behavioral health services. Research shows that to healthy school environments. For example, less than behavioral health conditions such as depression, 50 percent of the nation’s students have access to a anxiety and oppositional defiant disorder are directly full-time school nurse or school counselor, and less related to school avoidance behaviors and absenteeism. than 5 percent of the nation’s students have access to Providing students with access to school-based health services through a school-based health center. In behavioral health programs is a key strategy for addition, one in five U.S. schools reports unsatisfactory improving student attendance. For example, Baltimore indoor air quality, a known trigger of asthma attacks. City Public Schools expanded the school behavioral health services available to students by collaborating A healthy school environment includes regular access with health providers from the school and community to school health services (including physical, mental, to implement a full array of prevention, behavioral dental, vision and behavioral services), healthy school health promotion, early intervention and treatment food, physical activity, good indoor air in a clean programs for students. Preliminary results of the and well-maintained building, access to water and a initiative showed an increase in math and reading supportive school climate and culture. A closer look at assessment scores and in attendance from the previous several of these key factors includes: school year for students with access to the expanded behavioral health programming. School health services. School health services, including those delivered by school nurses and in Healthy breakfast and lunch. Providing students with school-based health centers, are key for ensuring healthy school meals, including breakfast and lunch, students have access to the care they need to manage is a key strategy for improving student attendance. the health conditions that result in missed school, Children who come from food-insecure families are including asthma, diabetes, ADHD, dental and vision more likely to be suspended from school, have higher problems and obesity. Providing students with access to school health services is a proven strategy for Green Clean Schools increasing student attendance. For example, Dallas Healthy Schools Campaign’s multi-faceted Green School District, where 90 percent of school campuses Clean Schools program provides resources to help have their own full-time nurses, has successfully shown schools clean better, smarter and safer. no difference in attendance between asthmatic and non-asthmatic students. The Dallas School District Learn more and access resources at: requires nurses to provide asthma management plans GreenCleanSchools.org. for every diagnosed child and also provide urgent care

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 5 absenteeism rates and have poor health compared Healthy school buildings. The condition of school to children who come from food-secure homes. In facilities directly affects absenteeism. Students are addition, obese children and adolescents have been less likely to attend schools in need of structural repair, found to report many more missed school days than schools that use temporary structures and schools the general student population. Ensuring students have that have understaffed janitorial services. For example, access to healthy school meals is a proven strategy for researchers in California found that poor elementary addressing food insecurity and childhood obesity and, school classroom ventilation rates are associated with as a result, improving student attendance. For example, increased illness-related absences. Student attendance research shows that universal breakfast programs can be improved by ensuring students are able to are directly associated with reduced absenteeism for attend school in a healthy school building with clean students, specifically minority students. air and quality facilities that are regularly and properly cleaned. Green cleaning, or cleaning for health while Physical education and physical activity. School- protecting the environment, is a particularly practical, based physical activity programs have also been cost-effective and high-impact approach to supporting shown to improve attendance by increasing school healthy indoor environments. Given that asthma is connectedness and by favorably affecting the health one of the leading predictors of student absences, status of children with asthma. In addition, higher improvements in classroom and school air quality physical fitness achievement is associated with are closely associated with improvements in student better school attendance rates and fewer disciplinary attendance. incidents involving drugs, alcohol, violence or truancy. The U.S. Department of Health and Human Services’ Providing access to healthy school environments is a Healthy People 2020 national objectives call for critical step in addressing chronic absenteeism and schools to increase the proportion of students who supporting students’ lifelong wellness. meet the recommended 60 minutes of physical activity each day and who participate in daily physical Learn More in the Full Report education and other physical activity opportunities This is section one of five in Addressing the Health- such as recess, after-school activities and active Related Causes of Chronic Absenteeism: A Toolkit transport. Ensuring students have the opportunity to be for Action. To access the other sections, visit: physically active for 60 minutes a day is a key strategy healthyschoolscampaign.org/chronic-absenteeism for supporting student attendance.

About Healthy Schools Campaign Healthy Schools Campaign (HSC) is dedicated to among parents, educators, students and policymakers making schools healthier places where all children can to help prepare this diverse group of stakeholders to lead learn and thrive. HSC advocates for children to have change for healthier schools at the school, district, state access to nutritious school food, physical activity, school and national levels. health resources, green schoolyards and clean air. HSC In partnership with Trust for America’s Health, HSC co- has a special focus on the wellness and environmental convenes the National Collaborative on Education and health issues affecting low-income students of color. Health, which is working to transform the conditions of We start with a social justice perspective and believe health in schools across the country and has a key focus this focus is especially critical in light of the vast health on chronic absenteeism. disparities our nation faces. HSC facilitates collaboration

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 6 Taking Action: Understanding Student Health Needs

Section Two

This section focuses on identifying key issues and tailoring your strategy to address the factors that are having the biggest impact on attendance.

EVERY CHILD DESERVES TO LEARN + THRIVE the school they are enrolled in at the start of each Identifying Health school year. These cards include key information regarding student health conditions, immunizations Issues in Your and medications. Compiling and examining this data Community can provide valuable information regarding the health of students in a given school and can be used to inform Students are absent for many different reasons, and the delivery of school health services and programming. no two communities are alike. Even more so than with other issues, it is important to identify what is Public health data systems. City and county happening in your community and tailor your strategy departments of public health track and share data to address the factors that are having the biggest regarding the health of their residents. This data can impact on student attendance. typically be broken down by age group, race, gender and ZIP code and can serve as an important tool A key step toward addressing the health-related causes in identifying the primary health conditions among of chronic absenteeism is understanding children’s children in a given area. Contact your local public health needs in your community. This understanding health department to see what children’s health data can play an important role in informing the types they collect and are able to share. of services and programs you and your partners implement in schools and in the community to support Hospital community health needs assessments. Non- better attendance. This review of health needs can profit hospitals are required to conduct community focus on the prevalence of health conditions such as health needs assessments once every three years childhood asthma and tooth decay. in order to maintain their non-profit status. These assessments are used to guide their investment in It is also critical to consider social, economic and the communities they serve. As a result, non-profit environmental factors in the community and school hospitals serving a given school district have data to understand the full scope of children’s health needs that can help schools better understand the health within your community and intervene accordingly. needs of their students. Reach out to the community These factors could include: benefit director of your local non-profit hospital to see if they are able to share the most recent results of their · Rates of access to clinical care, and where children community health needs assessments. access that care · Unemployment rates County Health Rankings & Roadmaps. County Health Rankings & Roadmaps is a tool developed by the Robert · Rates of violent crime Wood Johnson Foundation that measures the health of · Air pollution levels nearly all counties in the nation and ranks each county · Housing trends within its state. The rankings are based on a model of population health that emphasizes the many factors · Rates of food insecurity that, if improved, can help make communities healthier Factors you identify in any of these areas may lead you places to live, learn, work and play. Key measures to additional relevant data points. included in the County Health Rankings & Roadmaps are health outcomes, health behaviors, access to Key Data Sources clinical care, social and economic factors and measures Key sources of public data can shed light on the issues of the physical environment. You can access this tool at affecting students and their health. These sources of www.countyhealthrankings.org. data include:

School health information cards. Students across the country are required to submit health cards to

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 1 Youth Risk Behavior Survey. The CDC’s Youth Risk Learn More in the Full Report Behavior Survey, while focused primarily on risky This is section two of five in Addressing the Health- behavior rather than underlying health issues, includes Related Causes of Chronic Absenteeism: A Toolkit valuable data such as rates of asthma and obesity. for Action. To access the other sections, visit: Depending on your location, the survey data may be healthyschoolscampaign.org/chronic-absenteeism available at a county or district level.

State-level surveys. Surveys such as the California Healthy Kids Survey, are a valuable resource in states where they are available.

In addition to understanding the student health needs in your community, this data can be used to make the case to both the health and education sectors about the need to work together to support student health and success. Once you have developed a better understanding of student health needs, this information can be shared with key decision makers and used to inform the services and programs that are implemented to address chronic absenteeism.

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 2 Case Study: Unique Partnership Ensures Austin Students Have Access to School Health Services When a budget crisis in the late 1990s forced the Austin “One of the things we’ve been able to do is help Independent School District (AISD) to look at cutting coordinate the specialist kinds of care that helps that all school nurse and health positions in the district, child be healthy in the school setting,” Freeman says. local health care providers came together with district Another factor that allows this program to tailor itself is leadership to find a solution. the model it uses to determine the needs of each school, That solution was for AISD to partner with Dell called an acuity model. Every year, the program does an Children’s, the pediatric center for Seton Family of acuity analysis which looks at school enrollment; rates Hospitals, to provide school nurses and health staff in of free and reduced price lunch, which helps estimate AISD schools. insurance coverage and access; the number of illness or injury contacts for the previous year; and the number of “They understood that if you didn’t have school nurses, students who received case management due to chronic kids would be showing up in the emergency room,” says conditions such as asthma and diabetes. All of those Sally Freeman, the director of the Children’s/Austin ISD factors are weighted, and an analysis determines how Student Health Services program. many hours of a school nurse’s and a health assistant’s Initially, the entire program, including staff, was funded time a school might need. by the hospital, but the burden shifted back to the This type of analysis is gaining traction in the school district within just a few years as the district got back nursing world, Freeman says. on its feet financially. Today, the district pays for the full cost of the nurses’ and health staff’s salaries, while the “This allows us to address the needs of each school in a hospital contributes about $650,000 worth of in-kind fair and equitable manner,” she says. support, including human resources and legal services, In addition to constantly evaluating the needs of each management and oversight and continuing education school, the program also responds to changing needs for the health staff. within the district as a whole. One issue that has come The program includes both school nurses and health to the forefront in recent years is behavioral health. To assistants. More than 75 school nurses, covering about respond to that concern, the program developed a pilot four schools each, provide care to the district’s more program that contracted licensed social workers to see than 80,000 students. students during the day. The school nurses act as a referral coordinator. The students with behavioral health “School nurses serve as a triage person,” Freeman says. issues who receive counseling have fewer discipline “They help families to determine what level of care their referrals and are more likely to pass their classes and child would need, whether that’s going to the hospital or move on to the next grade. waiting to see their pediatrician.” This amazing partnership is just one example of how a From the start, Freeman says, the hospital kept detailed forward-thinking health system and a school district can data on cost and outcomes, which allows the program to partner together to ensure that students are getting the track its success. One of the focuses has been to prevent health care they need. hospitalization, especially when it comes to students dealing with complex medical conditions.

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 3 Taking Action: Addressing the Health-Related Reasons Students Are Absent

Section Three

This section focuses on school-based interventions to address the health conditions that have an especially significant impact on chronic absenteeism.

EVERY CHILD DESERVES TO LEARN + THRIVE The program teaches children with asthma ages 8 to Addressing Health 11 how to detect the warning signs of asthma, avoid Concerns their triggers and make decisions about their health. · U.S. EPA’s Tools for Schools: U.S. EPA’s Tools for While many issues contribute to health-related chronic Schools program is a comprehensive resource to help absenteeism, several conditions have an especially schools maintain a healthy environment in school significant impact and therefore can represent practical buildings by identifying, correcting and preventing opportunities for bringing about positive change. indoor air quality problems. This can reduce asthma triggers and create a healthier environment for This section identifies five health conditions shown everyone in the building. to have an especially significant impact on chronic absenteeism: asthma, oral health, behavioral health, · Green Clean Schools: Healthy Schools Campaign’s food insecurity and acute illness. These conditions have multi-faceted Green Clean Schools program provides high prevalence among children, disproportionately resources to help schools clean better, smarter and affect children of color and have a direct impact on safer. A key element of this approach is cleaning in student attendance. Research identifies proven or a way that supports healthy indoor air quality and promising school-based programs to address each of reduces asthma triggers. these health conditions. Key Partners Partners well-positioned to help address this issue Asthma include: · School staff, including school health team and Asthma is one of the leading causes of school maintenance team absenteeism, accounting for one-third of all days of · School-based health centers missed instruction. Children with persistent asthma are 3.2 times as likely to have 10 or more absences as · Community health providers their peers. Eight point three percent of children under · EPA office age 18 are currently diagnosed with asthma. Compared · American Lung Association local chapter to Caucasian children, asthma prevalence is higher in children who are Puerto Rican (2.4 times), African · Housing advocates American (1.6 times), and American Indian/Alaska · Before- and after-school programs Native (1.3 times). Spotlight: Dallas Addresses Asthma-Related Best Practices and Proven Interventions Attendance Gap through School Nursing Best practices and proven interventions include: Research clearly shows that children with asthma miss more school than their non-asthmatic peers. · American Lung Association’s Asthma Friendly According to the Centers for Disease Control and Schools: The Asthma Friendly Schools Initiative Prevention, children with persistent asthma are more provides a framework and tools that communities than three times as likely to have ten or more absences and schools can use to work together on a than their peers. However, this is not the case in comprehensive approach to asthma management, Dallas Independent School District, a district where including planning tools, policy recommendations 90 percent of school campuses have their own full and education programs. time school nurses. The school district, which serves · American Lung Association’s Open Airways for over 160,000 students, of which 89 percent come Schools: Open Airways for Schools is a program from low-income families, has successfully shown that educates and empowers children through an no difference between asthmatic and non-asthmatic interactive approach to asthma self-management. student attendance. In addition to providing the

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 1 majority of students with access to a full-time school when the first or second molars typically erupt. nurse, the school district requires school nurses to have · Dental preventive services: These programs provide an asthma management plan for every child identified services including screening, cleaning, fluoride with asthma and to provide bronchodilator treatment treatment and sealants. This type of program will to symptomatic children during school hours. Providing generally serve students in all grades. students with regular access to a full-time school nurse · Basic preventive and restorative dental services: has served as a highly effective strategy for supporting This type of program includes the full range of the connection between health and learning in Dallas. preventive services along with restorative services, such as basic fillings and simple extractions. Students Oral Health in all grades are offered services. School-based oral health programs may provide Children age 5-17 miss nearly two million school days services at a school clinic, in a room in the school in a single year due to dental health problems..Twenty building using portable equipment or in mobile vans percent of children age 5-11 have at least one untreated parked at the school. These services can also be decayed tooth. Untreated cavities are nearly twice as delivered through teledentistry. Using teledentistry, prevalent in Hispanic children (26 percent) compared specially trained dental health professionals—most to non-Hispanic white children (14 percent) aged 6-9, often dental hygienists—are deployed to community and are more than twice as prevalent for non-Hispanic sites, such as schools, to provide preventive care and black adolescents (25 percent) compared with non- basic treatments that essentially constitute a portable Hispanic white adolescents (9 percent) age 13-15. The pop-up clinic. percentage of children age 5-19 with untreated tooth decay is twice as high for those from low-income Key Partners families (25 percent) compared with children from Partners well-positioned to help address this issue higher-income families. include:

Best Practices and Proven Interventions · City or county health departments Best practices and proven interventions include · Hospitals and health centers community-based oral health programs, including · School-based clinics school-based sealant programs, free clinics and mobile programs. Community-based oral health · Dental schools and programs programs focus on bringing prevention and dental · Local dental health providers care to a local community. With a community-based · WIC or Head Start programs approach, students have a better chance of finding a dental home to receive ongoing comprehensive dental · Well child clinics care. The following types of community-based oral · Community centers health programs can be located in schools and have a · School staff, including school health team significant impact on student oral health issues: Spotlight: Addressing Chronic Absenteeism with · Dental screening: These programs provide screening Teledentistry in California for students in any grade level. No treatment is By leveraging familiar technology and a practical, cost- provided at the school; students with dental needs effective model called teledentistry, innovative care are referred to a local dental clinic. providers are bringing high-quality dental services to · Dental sealants: These programs provide screenings children in the school setting. The result: Students get and sealants for students in selected grades (typically the care they need to stay in class and learn second and sixth grade) to reach children at a time

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 2 The Pacific Center for Special Care and The Children’s 3-17, disproportionately affects urban minority youth Partnership collaborated on a successful teledentistry from poor families, who may not only be more likely demonstration program in California. They explain: to be affected, but also less likely to receive accurate “Typically, a dental hygienist will bring a portable diagnosis and treatment. dental chair, a laptop computer, a digital camera, and a handheld X-ray machine—which, together, can all fit Best Practices and Proven Interventions into the trunk of a car—to a site such as a preschool, Best practices and proven interventions include: elementary school or community center. Within · School-based behavioral health services: School- minutes, children and others who need care are getting based behavioral health services can play a critical state-of-the-art diagnostic, preventive and early role in preventing and addressing student behavioral intervention dental care.” health issues. School-based behavioral health Meanwhile, dentists are able to stay in their clinics services can be delivered by a school-based provider and focus primarily on addressing the most advanced such as a school psychologist or school social worker and complex needs of patients. From their clinics, or by a community partner. dentists also play a role in the care delivered in the · Positive behavioral interventions and supports: community: They review X-rays, assess care needs Positive Behavior Interventions and Supports (PBIS) and develop treatment plans while supervising the is a proactive approach to establishing the behavioral dental professionals who provide front-line care in supports and social culture needed for all students in the community. When more complex care is needed, a school to achieve social, emotional and academic the community dental professionals arrange for such success. care to be provided in the community setting or can · Wraparound services: Wraparound services are organize a follow-up appointment in the dentist clinic. individualized, community-based services that bring (Importantly, they can also work with the school to multiple systems together with the student and help address barriers that students may face in making their family to provide a highly individualized plan it to the appointment.) The demonstration program to meet the unique needs of the student, including found that about two-thirds of children can achieve intervention, culturally and linguistically relevant and maintain good dental health with care provided in services and progress monitoring. the community setting. Learn more about teledentistry and specifically about the results of the Pacific Center · Trauma sensitive schools: A trauma sensitive school for Special Care and The Children’s Partnership is a safe and respectful environment that enables demonstration project. students to build caring relationships with adults and peers, self-regulate their emotions and behaviors, and succeed academically, while supporting their physical health and well-being. Behavioral Health · Social and emotional learning: Social and emotional When students’ behavioral health needs are met, learning is the process through which children and they are less likely to be absent and more likely to adults acquire and effectively apply the knowledge, be engaged in and have a sense of connectedness to attitudes and skills necessary to understand and school. A total of 13-20 percent of children experience manage emotions, set and achieve positive goals, feel a behavioral health disorder in a given year. Yet only and show empathy for others, establish and maintain 25 percent of children in need of behavioral health positive relationships and make responsible decisions. care get the help they need. Minorities have less Research shows that social and emotional learning access to behavioral health services and are less can have a positive impact on students’ academic likely to receive needed care. ADHD, one of the most performance and behavioral health. prevalent behavioral health issues among students age

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 3 · Staff self-care: A key strategy for supporting student necessary to provide wraparound services to Mesa behavioral health is supporting the mental health County students. and well-being of school staff. Schools can ensure Along with the Colorado Department of Education, systems are in place to support school staff in caring Mesa County student services professionals created for themselves and providing them with training tip sheets for teachers about how to call families whose around how to manage their stress. students were exhibiting behavioral health problems; Key Partners this helped teachers feel more comfortable with calling Partners well-positioned to help address this issue families to express their concerns about students’ include: behavioral health. A common referral form and informational one-pagers about various mental health · Community mental health providers and agencies issues were developed, and school staff members were · Local departments of health and public health trained on how to refer students to services.

· Local courts and legal system The largest project that resulted from the work of · Local child trauma programs Building Bridges is a Social/Emotional Standards rubric · School staff, including the school health team, school outlining the expected measurable behaviors a child nurses, guidance counselors and behavioral health might exhibit at certain stages of development. These team members rubrics help school and community agency staff as well as families and teachers “talk the same language” · School-based mental health centers and understand social/emotional stages in a student’s · Community Anti-Drug Coalitions of America development.

Spotlight: Increasing Collaboration for While challenges remain, the program has had a Behavioral Health in Mesa County, Colorado meaningful impact and serves as a useful model for The Building Bridges for Children’s Mental Health other districts. Learn more about Building Bridges. project in Colorado is designed to build a statewide system for connecting public schools and local behavioral health systems, thereby increasing access to behavioral health services and improving outcomes Food Insecurity and for school-aged children. It integrates a System of Care Related Conditions within a Positive Behavioral Interventions and Supports (PBIS) model. Food insecurity and related conditions such as obesity are closely linked to absenteeism. Children who come In 2009, Mesa County began a pilot of the Building from food-insecure families are more likely to be Bridges program. Building Bridges helped the school suspended from school, have higher absenteeism rates district make a stronger connection to its community and have poor health compared to children who come partners, particularly the mental health provider, from food-secure homes. Children who are obese are Colorado West (now Mind Springs Health), by 1.7 times more likely to have 10 or more absences in a emphasizing school-community collaboration to given year than their non-obese peers. 21 percent of improve behavioral health supports. As a result of children under age 18 live in households that have been Building Bridges, teachers and school staff—including food insecure at some point during the yearand 31.8 bus drivers—were trained on how to identify and percent of children and adolescents are overweight or refer students while supporting those students in obese. Food insecurity is more than twice as prevalent the classroom through a PBIS model. This allowed among children in households headed by African students to receive the services they needed as well Americans (36 percent) or Hispanics (30 percent), as the school community—teachers, administrators, than in those headed by Caucasians (15 percent). The counselors and social workers—the collaboration

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 4 proportion of households where children had “very low · High quality physical activity programs: High quality food security,” is between three and four times as high physical activity programs have been proven to in African American or Hispanic households as it was in increase student connectedness with their school Caucasian households. and support current and future healthy habits among children that reduce their risk of being overweight Best Practices and Proven Interventions or obese. The Centers for Disease Control and Best practices and proven interventions include: Prevention offers guidance on how to establish high · Universal school breakfast programs: Universal quality physical activity programs school breakfast refers to any program that offers Key Partners breakfast at no charge to all students, regardless Partners well-positioned to help address this issue of income status. On average nationally, only 47 include: children eat free or reduced-price school breakfast for every 100 who receive free or reduced-price school · Local departments of health and public health lunch. Studies show that universal school breakfast · Teachers unions programs significantly increase student participation · Food service directors in the National School Breakfast Program. Research also shows that children who participate in programs · Local food banks that offer a breakfast free to all students have lower · Local anti-hunger groups, including Feeding America rates of absence and tardiness. · School staff, including food services team and facility · Backpack programs: More than 21 million children and maintenance team qualify for free or reduced-price meals through the · Community food and fitness organizations National School Lunch Program and the National School Breakfast Program. For many of these children, · Local health care providers school meals may be the only meals they eat. School · Farmers markets backpack programs help children get the nutritious and easy-to-prepare food they need to get enough Spotlight: Universal Breakfast in the Classroom to eat on the weekends. Feeding America offers in Chicago Public Schools information on how to find out if your local food In 2011, Chicago Public Schools (CPS) instituted a pantry offers a backpack program. universal breakfast in the classroom program to help ensure all students are well-fed and ready for the School pantry programs: School-based pantries · school day. Universal breakfast, or offering breakfast are located on the grounds of a school to provide free to all students, helps remove the stigma of an easily accessible source of food assistance participating in school breakfast and is proven to to low-income students and their families. They increase participation. When CPS schools offer have set distribution schedules and offer ongoing breakfast in the classroom, a total of 60 to 70 percent food assistance services. Feeding America offers of students participate, said Leslie Fowler, director of additional information on these programs.

Value of Healthy School Environments A central strategy for addressing health-related chronic services, healthy school food, physical activity, good absenteeism—for these issues and many others—is indoor air in a clean and well-maintained building, ensuring that children are able to attend school access to water and a supportive school climate and in healthy school environments. A healthy school culture. For more, see “What is the Impact of the School environment includes regular access to school health Environment?” in Section One.

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 5 nutrition support services at CPS. When breakfast In addition, children of color are less likely to be able to is offered outside the classroom—before school in afford prescription medications to treat acute illness, the cafeteria—only 8 to 18 percent of total students such as ear infections, and less likely to have medical participate, she said. “That says to me that those insurance that enables them to see a specialist when students are not ready for the school day,” Fowler said. needed. “Breakfast in the Classroom ensures all our students are active thinkers when the school day starts.” Best Practices and Proven Interventions Best practices and proven interventions include: Breakfast is even more important for students who qualify for free or reduced-price lunch and might Green Clean Schools: Green cleaning programs are a not have access to breakfast at home. During the proven strategy for protecting the environment and 2005-2006 school year, only 28.7 percent of CPS supporting student health. Ensuring that schools are students receiving free and reduced-priced lunches properly cleaned is a key strategy for reducing the through the school meal program participated in the prevalence of acute illness among children, in addition breakfast program. During the 2013-2014 school year, to addressing chronic conditions such as asthma. thanks in large part to breakfast in the classroom, that Healthy Schools Campaign’s multi-faceted Green Clean percentage rose to 58.1 percent. Schools program provides resources to help schools clean better, smarter and safer. A key element of this The approach has been successful because of hard approach is cleaning in a way that supports healthy work within the district as well as the support of indoor air quality and reduces asthma triggers. parents and the community. Parents involved in Parents United for Healthy Schools, Healthy Schools Handwashing education and support: Regular Campaign’s parent-led advocacy coalition, were handwashing, particularly before and after certain instrumental in the effort to make breakfast in the activities, is one of the best ways to remove germs, classroom a reality in CPS. With the help of Parents avoid getting sick and prevent the spread of germs United, CPS began piloting breakfast in the classroom to others. The Centers for Disease Control and in the fall of 2007. The pilot saw immediate results. Prevention offer many resources on how to support Participation in the program increased 250 percent, handwashing in schools and educate students about and student test scores improved more than nine good handwashing practices. percent. Madero Middle School on Chicago’s southwest Influenza vaccine awareness campaign: The Centers side began serving breakfast in the classroom during for Disease Control and Prevention recommend that the 2009-2010 school year. “It helps students to focus everyone six months of age and older get seasonal and to be more alert,” said Madero principal Jose influenza vaccines each year. Schools can play a key Luis Illanes. “Children are more prepared to start the role in educating parents, students and staff about instructional day when they have breakfast.” the importance of getting an annual influenza vaccine. School nurses can play an especially important role in these campaigns. Acute Illness Key Partners Acute illnesses, such as influenza, strep throat or Partners well-positioned to help address this issue ear infections, have a direct and significant impact include: on attendance. Roughly 40 percent of school-aged children missed three or more days of school in the past · Local departments of health and public health year due to acute illness. Low-income children of color · Teachers unions are disproportionately impacted by acute illness. For · Local environmental health agencies and example, there are significant racial and socioeconomic organizations disparities among children with frequent ear infections.

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 6 · Regional chapter of the U.S. Environmental Protection Central Texas Education Funders and school districts, Agency launched a regional approach to increase student · Local hospitals, particularly children’s hospitals attendance called Missing School Matters. E3 Alliance determined that a major cause of absences was student · Local health care providers, including pediatricians health. E3 Alliance’s 2013 Absence Reasons Study found that the single largest reported cause of Central Spotlight: Fighting Chronic Absence with a Flu Shot Texas student absences—at 48 percent—was acute Schools in Central Texas had a problem. Students in illness. The flu emerged as the cause of more absences that region were missing more days than the state than all other immunizable diseases combined. average at every single grade level. This absence With that data in hand, the partnership launched problem hits Texas schools on two fronts: student the largest in-school flu immunization campaign in achievement and funding. Data shows high school Texas history, giving more than 6,500 vaccines at 56 students who miss 10 or more days of school are three primarily Title 1 schools in five districts. E3 Alliance times more likely to drop out than students who miss partnered with local and public health partners to five days or fewer. In some states, Texas included, obtain and administer the vaccines. school funding is based on a figure called “average daily attendance” rather than total enrollment. That means Just like Central Texas, schools across the country are that schools receive funding only for students that are struggling with chronic absenteeism. Any community in school. That also means that the more students are can make a positive impact on the lives of students by absent—for whatever reason—the less funding the starting with the data and a commitment to unpacking school gets. the reasons why students are missing school. With this as a starting point, any community has the ability Enter E3 Alliance, a regional, data-driven education to ensure that students have a better opportunity to collaborative based in Austin, Tex., working to succeed in school. strengthen education to drive economic prosperity in the region. E3 Alliance completed an analysis of school Learn More in the Full Report year 2010-2011 and found that there were 2.4 million This is section three of five in Addressing the Health- student absences in Central Texas in the year. Half of Related Causes of Chronic Absenteeism: A Toolkit Central Texas students missed more than six class days for Action. To access the other sections, visit: per year, and accounted for 85 percent of all absences. healthyschoolscampaign.org/chronic-absenteeism Chronic absence also disproportionately affected low-income students. Low-income students in Central Texas had the highest absence rates of any urban area in the state while non-low-income students missed a similar amount of days as their peers across the state.

E3 Alliance figured out that if they could increase average attendance by just three days, Central Texas districts would gain $34 million in annual revenue from the state that could then be used to improve educational outcomes for all students.

In the spring of 2011, E3 Alliance, in partnership with the Austin Area Research Organization (AARO),

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 7 About Healthy Schools Campaign Healthy Schools Campaign (HSC) is dedicated to among parents, educators, students and policymakers making schools healthier places where all children can to help prepare this diverse group of stakeholders to lead learn and thrive. HSC advocates for children to have change for healthier schools at the school, district, state access to nutritious school food, physical activity, school and national levels. health resources, green schoolyards and clean air. HSC In partnership with Trust for America’s Health, HSC co- has a special focus on the wellness and environmental convenes the National Collaborative on Education and health issues affecting low-income students of color. Health, which is working to transform the conditions of We start with a social justice perspective and believe health in schools across the country and has a key focus this focus is especially critical in light of the vast health on chronic absenteeism. disparities our nation faces. HSC facilitates collaboration

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 8 Taking Action: Building Effective Partnerships to Support Student Health

Section Four

This section focuses connecting with partners in the health and public health sectors that are well- positioned to support schools in addressing the health-related causes of chronic absenteeism.

EVERY CHILD DESERVES TO LEARN + THRIVE Why Is the Health Sector Motivated to Address Building Partnerships Chronic Absenteeism? The time is right for the health and education sectors While many school leaders recognize the importance to work together to address chronic absenteeism and of healthy school environments for addressing chronic promote student health. In addition to fundamental absenteeism, the scale of the work ahead can seem mission-based motives, leaders in the health sector daunting—especially in the context of widespread and public health sector are motivated to be part of budget cuts and a lack of resources for supporting this work by several powerful factors: provisions of the health and wellness. However, schools do not need to Affordable Care Act; recognition of the cost savings take on this great challenge alone. Health and public inherent to community-based preventive care; and an health sectors can play a key role in supporting efforts understanding that educational attainment directly to address chronic absenteeism. supports lifetime health. With over 49 million children Who Are Key Partners in the Health and Public attending public schools across the country, partnering Health Sectors? with schools presents an important opportunity for Partners in the health and public health sectors are the health sector to reach vulnerable and underserved well-positioned to support schools in addressing the children. health-related causes of chronic absenteeism. This may Provisions of the Affordable Care Act: With the range from technical assistance to funding for health passage of the Affordable Care Act, the country’s services and many areas in between. Such partnerships health care system is transforming. It increasingly represent a rapidly evolving area where communities prioritizes prevention, community-based care, nationwide are finding innovative ways to collaborate population health, care coordination and chronic around shared goals for children’s health. disease management. New opportunities—and Possible partners include: motivations—exist for the health sector to engage with and support schools. Medical providers such as · Local hospitals, particularly children’s hospitals hospital systems can meet key requirements of the · Accountable Care Organizations, Managed Care Affordable Care Act by partnering with schools and Organizations and health plans responsible for providing resources to support schools in addressing providing coverage to students in your community many of the factors that contribute to health-related · Local community benefits experts—this could be chronic absenteeism. One example of this is known as the individual responsible for overseeing community the Community Benefit requirement. To maintain their benefits or community outreach at one of the local, tax-exempt status, non-profit hospitals are required non-profit children’s hospitals to provide measurable benefits to the communities they serve. The Affordable Care Act pushes this · Community organizations dedicated to supporting requirement beyond providing free care to uninsured children’s health patients and creates an expectation that hospitals · State or local advocacy organizations invest in the health of their surrounding communities. If · Public health agencies or public health department a hospital has identified obesity and asthma as health needs in its community, for example, that hospital may · Pediatricians, local chapter of the American Academy invest community benefit resources in school physical of Pediatrics activity programs, nutrition education and school These partners will vary greatly by community; nursing focused on asthma management. the most practical partnerships will emerge from Cost savings of community-based preventive care: the primary causes of chronic absenteeism and Our nation’s health care system transformation opportunities for change identified in your school provides incentives for the health sector to identify community. ways to reduce costs over time while improving health

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 1 outcomes. Focusing on community-based preventive Leading Health Indicator. Leaders in the health and care is a natural way to do this. For example, a hospital public health sectors who recognize this connection are may cover the cost of employing a school nurse who motivated to support education in part as a strategy provides asthma management in the school setting, to improve the long-term health of our population as a recognizing that this is far more cost-effective than whole. providing an ambulance response and emergency room treatment for asthma attacks. Of course, this strategy What Are Key Opportunities for Collaboration? brings great benefits beyond cost savings: it helps keep Health-related chronic absenteeism is a natural area students in school (rather than the hospital), school of collaboration for the health, public health and nurses can provide management plans to reduce the education sectors. The issue provides a clear lever frequency and severity of asthma attacks and school for leaders in each sector to rally resources and take nurses can even bring a public health approach to action. In each community, leaders from these sectors evaluating the school environment to identify and can identify areas of opportunity to work together with address asthma triggers such as mold or certain significant benefits for children’s academic success cleaning products. With applications ranging from and long-term health. Key areas of opportunity for dental care to flu shots and much more, this approach collaboration to address this issue include: can be a key element of addressing health-related Using data to identify the health-related reasons for chronic absenteeism. absenteeism: To effectively address health-related Positive impact of educational attainment on long- chronic absenteeism, it is important for leaders to term health outcomes: Health and education are have information about what health issues have the critically linked. Much of the research cited in this greatest impact on attendance and what interventions report focuses on the ways that health has an impact have proven effective in addressing those issues. The on opportunities to learn; in fact, the connection works key is using data to identify and intervene early, before both ways. Research shows that adults with higher students have missed so much school they are unable educational attainment report a better health status to catch up. When possible, it is critical to use the data than those with lower education levels. Obtaining a available to determine the underlying causes of chronic college education correlates with lower rates of health absenteeism. The health and public health sectors have conditions and longer life expectancy. Healthy People access to data that can help leaders in the education 2020, a comprehensive set of key disease prevention sector understand the health-related causes of chronic and health promotion objectives, recognizes the absenteeism. Many local public health departments percentage of students who receive a high school have data organized by zip code on prevalent health diploma four years after starting ninth grade as a issues, including asthma, obesity, community violence

Engaging Health Providers in Promoting Good Attendance Health providers can be powerful advocates for good may—and should—still attend school when they attendance, particularly when it comes to health-related experience these health conditions. absenteeism. Attendance Works has developed a robust set of In addition to the many serious health issues at the root resources and materials for health providers, as of health-related chronic absenteeism, students may well as resources for school district leaders to use in miss school unnecessarily for perceived health issues engaging health providers in discussing the importance such as rashes or minor headaches. Health providers of attendance. To access these resources, visit can communicate with students and families about attendanceworks.org. the importance of attendance and clarify that students

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 2 and behavioral health. In addition, non-profit hospitals Creating healthier schools and home environments: are now required to conduct community health needs Well-maintained school buildings, healthy school food, assessments (CHNA) every three years to identify and opportunities for physical activity and clean indoor air address the health needs of their communities. Schools all play a huge role in students’ health and therefore can reach out to local non-profit hospitals to participate in their attendance at school. These areas are rich in the CHNA process or request data that is collected. with opportunities for collaboration, particularly with public health departments and community partners Providing health services in school or the community: that can provide support for physical activity and The health and public health sectors can play an nutrition education programs. Public health and other important role in making sure schools have the government agencies such as local EPA representatives resources to meet the health needs of their students. are also well-positioned to provide resources related For example, local health providers can partner with to indoor air quality and health-promoting building schools to establish school-based health clinics or maintenance strategies. Public health and government mobile care vans and deliver vision, hearing and agencies can also collaborate with schools to engage dental screenings. Local hospitals can ensure that parents around the importance of creating healthy schools have adequate levels of staffing in school home environments and connect parents with nursing, mental health and other specialized support resources available in the community. areas by working with schools to identify staffing goals and providing support staff when needed. Many Engaging health providers to deliver the message cities, including Toledo and Austin, are successfully on attendance at check ups and appointments: implementing this approach. In addition to direct The medical community can play a key role in service delivery, the health and public health sectors communicating the importance of attendance and can deliver health education in classrooms and support flagging any health factors that are preventing children parent and staff wellness programs. from attending school. For example, pediatricians

Case Study: Cross-Sector Collaboration to Address Chronic Absenteeism in New York City In the summer of 2010, following a report about the were piloted in 25 schools in year one, 50 schools in year pervasiveness of chronic absenteeism in New York City two, and 100 schools in year three, with over 60,000 schools, Mayor Michael Bloomberg’s administration students. Key strategies included using data to identify undertook one of the nation’s most ambitious cross- at-risk students and develop early warning flags to sector efforts to tackle this issue in New York City public identify for early intervention students at risk of chronic schools. Acknowledging that chronic absenteeism absenteeism; creating a Success Mentor Corps, reaching is a complex, under-recognized problem affecting nearly 10,000 at-risk students; sharing strategies to academic achievement, dropout rates and juvenile link schools to existing community resources (including crime, the mayor created an interagency task force to city preventive service providers); and including chronic develop a comprehensive set of strategies to combat absenteeism as a metric in school progress report cards this problem. Key partners included the Department of and evaluations a the Department of Education. Education, Administration for Children’s Services, the As a result of this initiative, task force schools Department of Homeless Services, the Department of significantly and consistently outperformed comparison Health, the Department for the Aging, NYC Service, the schools in reducing chronic absenteeism. Students in Department of Youth and Community Development, the the task force schools were less likely to be chronically NYC Police Department, as well as private sector and absent than students in comparison schools. Read the community partners. full report on this initiative. The strategies developed by the interagency task force

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 3 can ask children and their families about their school Addressing chronic absenteeism is a natural area for attendance during their annual check-up and discuss collaboration among the education, health and public the importance of good attendance, especially in early health sectors: it brings great benefits not only for grades, with families. students’ learning but for their lifetime health as well.

Supporting students in responding to trauma and Learn More in the Full Report mental health issues: The health and public health This is section four of five in Addressing the Health- sectors can play a powerful role in increasing access Related Causes of Chronic Absenteeism: A Toolkit to mental health services in schools. These partners for Action. To access the other sections, visit: can also support schools in building their own healthyschoolscampaign.org/chronic-absenteeism capacity in this area, such as by providing professional development to educators on recognizing early warning signs of mental health problems and understanding how violence and trauma have an impact on student learning. Health and public health partners can share data to help school leaders identify the mental health and trauma-related risk factors, such as violence, in the surrounding community and ensure students have adequate support to navigate those factors.

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 4 Taking Action: Building Capacity

Section Five

This section focuses on building the capacity of the school and key partners to effectively address chronic absenteeism

EVERY CHILD DESERVES TO LEARN + THRIVE implement effective interventions to address those Building Capacity needs. Contacting your local public health agency to Once the decision has been made to implement an discuss chronic absenteeism and explore strategies for effort to reduce chronic absenteeism, it is critical to improving student health can serve as a key strategy generate school-wide support for the effort and build for bringing additional resources and support to the capacity of the school and key partners to engage schoolwide efforts to address chronic absenteeism. in this work. Accessing existing resources, ensuring Local hospitals and health providers: Local hospitals adequate training and supporting the sustainability and health providers can also provide training and of your work are key steps toward building the support to school districts as they work to understand capacity of your school district to implement effective student health issues. This can include sharing interventions. community health needs assessments and working with school staff to understand their implications Key Partners and Resources There are many partners and resources available to for their student body and supporting the delivery support school staff in understanding the health- of programming to meet the needs identified. Local related causes of chronic absenteeism and in health providers can also play an important role in implementing interventions to address the root causes asking parents and students about attendance and in a given community. These include the following: emphasizing the importance of attending school every day. Specialized instructional support personnel: Specialized instructional support personnel include Community organizations: Community organizations, school nurses, school counselors, school social workers, including local chapters of United Way, children’s school psychologists and other qualified professional advocacy organizations and social justice organizations, personnel such as speech language pathologists can offer additional resources and support for efforts involved in providing services to meet student needs. to address chronic absenteeism. These organizations These individuals can play a key role in helping school can assist with program implementation and providing staff and school administrators understand the health targeted support to high need populations. issues impacting students in a district and/or school State education agencies: Under the new federal and can also play a key role in delivering evidence- education law, the Every Student Succeeds Act (ESSA), based programs and services to meet those needs. states are required to include chronic absenteeism Given that not every school has access to these in their state report cards which are submitted to individuals, increasing access to these individuals is a the U.S. Department of Education. As this new law is key strategy for addressing the health-related causes of implemented (states will be required to comply with chronic absenteeism. the new law at the start of the 2017-2018 school year), School-based health centers and community clinics: it can be expected that states will have guidance and School-based health centers can also play a critical resources to support school districts in addressing role in meeting student health needs and in helping chronic absenteeism and reducing chronic absenteeism schools understand the leading health issues impacting across their state. In addition, a number of states, students in a community. In addition to school-based including California, Utah and Illinois, have existing health centers, community clinics can also play this role statewide initiatives to address chronic absenteeism. and help schools both understand student health needs Contact your state education agency to learn more and address those needs. about what is taking place around chronic absenteeism in your state and what resources are available. Public health agencies: Local public health agencies Additional information regarding state level efforts can both share data with school districts to help to address chronic absenteeism is available on the them understand their student health needs and Attendance Works website.

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 1 Attendance Works: Attendance Works is a national Regional offices of the USEPA and USDA: Regional and state initiative that promotes awareness of the offices of both the USEPA and USDA can offer important role school attendance plays in achieving extensive resources to school districts on supporting academic success, starting with school entry. Their student health and wellness. For example, your regional goal is to ensure that every district in the country EPA office can connect you with information regarding not only tracks chronic absence data beginning in how to improve indoor air quality (a key contributor kindergarten or earlier, but also partners with families to asthma) and key local partners. In addition, the and community agencies to intervene when attendance USDA can connect you with resources regarding meal is a problem for children or particular schools. programs for low-income families, including the school Attendance Works has published a number of tools meal program, to address food insecurity which is to support states and school districts in building the another health-related cause of chronic absenteeism. capacity to track chronic absence data and develop effective interventions. These tools and technical Ensuring Sustainability assistance resources are available online. Ensuring the sustainability of efforts to address chronic absenteeism is key to their success. Key strategies for U.S. Department of Education: In October 2015, the supporting sustainability include: U.S. Department of Education launched the Every Student, Every Day initiative to support coordinated Cross-sector collaboration: The health sector can community action that addresses the underlying play an important role in implementing effective causes of local chronic absenteeism, including interventions and helping school districts meet student health issues. As a part of this launch, the student health needs and in turn supporting academic U.S. Department of Education released its Community achievement. In addition, the health sector stands Toolkit to Address and Eliminate Chronic Absenteeism. to benefit from working with schools to support More information about the Every Student, Every Day student health and wellness given that research shows initiative can be found here. delivering health services and programming in schools

Supportive Policy The conditions that support student health and good by on-the-ground knowledge, and education leaders attendance do not appear by accident or luck; they are well-positioned to share this valuable insight with develop in the context of policy decisions made at the policymakers. federal, state and district levels. Healthy Schools Campaign advocates for policy The consequences of these policy decisions are not that supports health and education at the national, always intentional. In the past decade, for example, state and local levels. In partnership with Trust for a combination of policies prioritizing time spent on America’s Health, HSC also co-convenes the National academic subjects led schools across the country to Collaborative on Education and Health, which is working eliminate time for recess, with adverse outcomes for to transform the conditions of health in schools across students’ health and school connectedness. the country and has a key focus on chronic absenteeism.

When policies are being debated and developed, leaders We invite you to stay informed and lend your voice to in the education and health sectors can play a powerful the policy dialogue that shapes the conditions for health role in ensuring that policymakers understand the in our schools. To learn more and sign up to receive potential impact of their decisions on student health and updates, visit healthyschoolscampaign.org/subscribe. learning. Policy is most meaningful when it is informed

Addressing the Health-Related Causes of Chronic Absenteeism: A Toolkit for Action healthyschoolscampaign.org/chronic-absenteeism · 2 is a proven strategy for improving quality of and access school health services, including both physical and to care in addition to reducing health care expenditures. mental health services. In the first of these changes, School districts can also partner with additional local the Centers for Medicare and Medicaid Services sectors including housing, transportation, environment (CMS) changed its regulation to allow Medicaid and justice to support this work. Reaching out to local reimbursement of services recommended by a agencies and partners can help ensure cross-sector physician and implemented by providers such as support for this work and leverage additional resources. community health workers. In states that choose to implement this new flexibility, Medicaid programs Multi-sector data and accountability systems: An will be able to cover numerous interventions in school additional strategy for ensuring the sustainability of this settings carried out by non-clinical school personnel work is to support the inclusion of chronic absenteeism including health care aides, asthma educators and data in other sectors’ data systems and accountability other community health workers. Second, CMS systems. For example, working with local hospitals to removed a barrier known as the free care policy and include chronic absenteeism rates in community health clarified that health providers can bill Medicaid for needs assessments can play a key role in ensuring services delivered to the general student population in hospitals remain committed to this issue and think schools. In states that choose to implement this change, strategically about how to implement efforts to address Medicaid reimbursement will be available for health this problem. In addition, including rates of chronic services delivered by Medicaid-eligible providers in absenteeism in public health data sets can increase schools, such as asthma management, immunizations, awareness about the issue and its connection to screenings and acute care. By increasing resources children’s health and build broader support for school for health care in schools, these changes can increase district efforts. access to school health services for all students. To Multiple funding sources: School districts and partners learn more about these changes, see Healthy Schools can consider how to effectively braid and blend funding Campaign’s school health services policy guide. to support this work. Braiding diverse streams of Learn More in the Full Report funding, including public and private grant programs, can help ensure these efforts are not dependent on This is section five of five in Addressing the Health- a single source of funding, while engaging multiple Related Causes of Chronic Absenteeism: A Toolkit partners. for Action. To access the other sections, visit: healthyschoolscampaign.org/chronic-absenteeism Increased access to resources through Medicaid: A series of recent regulatory changes has created new opportunities for accessing Medicaid resources for

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