Children with both chronic health needs and health-related social needs had the highest adjusted estimated probability of missing 11 or more school days because of illness or injury, according to a nationally representative cross-sectional study published in JAMA Pediatrics.
The analysis included 66,752 US children aged 6 to 17 years in the 2022 to 2023 National Survey of Children’s Health, representing 49.3 million children. The primary outcome was elevated health-related school absenteeism, defined as 11 or more missed school days in the prior 12 months because of illness or injury.
Overall, 6.8% of children met that endpoint, representing an estimated 3.4 million children. More than half the sample — 52.5%, representing 25.9 million children — had both chronic health needs and health-related social needs, highlighting the substantial overlap between medical and social challenges among US school-age children.
Chronic health needs included children with special health care needs status or one of 27 chronic health conditions. Health-related social needs included housing instability, food insufficiency (a measure of food insecurity), parent health needs, or exposure to adverse childhood experiences (ACEs).
In adjusted analyses, the estimated probability of elevated health-related school absenteeism was 9.4% among children with both chronic health needs and health-related social needs, compared with 1.8% among children with neither. The estimated probability was 4.4% among children with chronic health needs only and 3.7% among children with health-related social needs only.
Children with special health care needs had an adjusted estimated probability of elevated health-related absenteeism of 12.2%, compared with 4.6% among those without that status.
Among individual conditions, some of the strongest associations were observed among children with depression, chronic pain, headaches, anxiety, and attention-deficit/hyperactivity disorder. Adjusted estimated probabilities of elevated absenteeism were 18.7% among children with depression, 18.2% among those with chronic pain, 17.8% among those with headaches, 14.8% among those with anxiety, and 11.3% among those with attention-deficit/hyperactivity disorder, compared with 5.7%, 5.7%, 6.0%, 5.1%, and 5.8%, respectively, among children without those conditions.
Developmental and neurocognitive conditions were also associated with higher adjusted probabilities of elevated absenteeism, including developmental delay (14.0% vs 5.9%), speech or language disorder (11.0% vs 6.1%), and learning disability (11.5% vs 6.0%).
Among health-related social needs, adjusted probabilities were higher among children with housing instability (10.3% vs 5.6%), food insufficiency (10.2% vs 6.3%), and parent health needs (8.2% vs 4.7%).
The probability of elevated absenteeism also increased with cumulative ACE exposure, rising from 4.2% among children with no ACEs to 6.9% among those with one ACE, 10.4% among those with two to three ACEs, and 17.0% among those with four or more ACEs.
The researchers generated national estimates using survey weights and adjusted models for sex, age, race and ethnicity, and household income. Race and ethnicity were analyzed as social constructs in the context of structural and institutional discrimination.
The findings should not be interpreted as causal. The study was cross-sectional, and absenteeism was reported by caregivers, introducing the potential for recall bias. In addition, the study outcome differed from the standard definition of chronic absenteeism, which is typically based on missing 10% of the school year, or approximately 18 days, for any reason.
The survey measure also did not capture absence patterns or other reasons for missing school that may relate to health or well-being, such as transportation barriers, disciplinary exclusions, or school refusal. The researchers noted that the chronic health and social needs included in the analysis were not comprehensive.
The study authors suggested pediatric clinicians could integrate school attendance screening into routine health maintenance visits and consider attendance a “vital sign” of child well-being and functioning.
“These findings underscore that school attendance is a marker of child health and equity and highlight the need for coordinated strategies across health care, household, and school contexts,” wrote lead study researcher and pediatrician Michelle Shankar, MD, of Children’s Hospital at Montefiore Einstein, Albert Einstein College of Medicine, Bronx, New York, and colleagues.
Co-researcher Marina Reznik, MD, reported grants from Monaghan Medical Corporation, the Stony Wold-Herbert Fund, and the National Institutes of Health/National Heart, Lung, and Blood Institute outside the submitted work. Co-researcher Rebecca Dudovitz, MD, reported serving as a board member of The Los Angeles Trust for Children’s Health. No other conflicts of interest were reported.
Source: JAMA Pediatrics