Commentary | Education

A look at the health-related causes of low student achievement

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EPI Research Associate Richard Rothstein published this exploration of the ways poverty and poor health impact learning, on March 14, 2011, on the Ed 100 blog.

A distinguished and diverse coalition of education, health, and social service experts, in a their campaign for a Broader, Bolder Approach to Education, have issued a statement calling for the establishment of school-based clinics in schools serving disadvantaged children as one of the most important strategies for raising the achievement of disadvantaged children. The California School Health Centers Association (CSHC) is a statewide organization that advocates for, disseminates information about, and provides training and other resources for operators of, and those interested in starting, school-based health centers.

Overall, lower-class children are in poorer health.

Those with vision problems have difficulty reading. In the United States, 50 percent of poor children have vision impairment that interferes with academic work, twice the normal rate. Lower-class children may be more likely to have vision problems because of less adequate prenatal development than middle-class children whose pregnant mothers had better medical care and nutrition. Visual deficits also arise from disadvantaged children being placed in inexpensive low-quality child care settings where they watch too much television, activity that does not develop hand-eye coordination and depth perception – 42 percent of black fourth graders watch six hours or more of television a day, compared to 13 percent of whites. Middle-class children more likely have manipulative toys that develop such coordination. A longitudinal study of entering kindergarteners reveals that fine motor skill development at age 5 is a stronger predictor of later mathematics and reading performance than is kindergartners’ pre-literacy knowledge (of the alphabet, of counting numbers, of phonemes).

Lower-class children also have more hearing difficulties, possibly because of untreated ear infections that occur in children whose overall health is less robust. Ear infections are easily treatable for children with access to regular pediatric care. But lower-class children with less access to such treatment are less attentive, on average, in school.

Children without dental care have more toothaches; untreated cavities are nearly three times as prevalent among poor as among middle-class children. Although only some cavities produce toothaches, children with toothaches pay less attention in class and are more distracted during tests, on average.

Children who live in older buildings have more lead dust exposure that harms cognitive functioning and behavior. High lead levels also contribute to hearing loss. Low-income children have dangerously high blood lead levels at five times the rate of middle-class children.

Lower-class children, particularly those who live in densely populated city neighborhoods, are also more likely to contract asthma – the asthma rate is substantially higher for urban children, for those whose families are on welfare, and for those from single parent or poor families. Asthma is provoked partly from breathing fumes from low-grade heating oil, diesel trucks, and buses (school buses idling at schools are a serious problem); excessive dust and allergic reactions to mold, cockroaches, and secondhand smoke also contribute. In neighborhoods with high asthma rates, children suffering from the disease are more likely to live in homes where adults smoke.

Asthma keeps children awake at night. If attending school, asthmatics are more likely to be drowsy and inattentive, more irritable and with more behavioral problems, and more likely to refrain from exercise and thus be less physically fit. Middle-class children typically get treatment for symptoms, while low-income children get treatment less often. Asthma has become the biggest cause of chronic school absence, with sufferers from low-income families more likely to miss school than those from middle-class families.

Youngsters whose mothers consumed alcohol during pregnancy have more difficulty with academic subjects, are less able to focus attention, have poorer memory skills, less ability to reason, lower I.Q.’s, less social competence and more aggression in the classroom. In adolescence, these children continue to have difficulty learning. Fetal alcohol syndrome, a collection of the most severe cognitive, physical and behavioral difficulties experienced by children of prenatal drinkers, is ten times more frequent for low-income black than for middle-class white children.

Smoking in pregnancy
also contributes to lower achievement. Children of mothers who smoked prenatally do more poorly on cognitive tests, and their language develops more poorly. They have more serious behavioral problems, more hyperactivity, and commit more juvenile crime. Thirty (30) percent of poor women smoke, compared to 22 percent of non-poor women. During pregnancy, one-fourth of high school dropouts smoke, 50 percent more than the rate for high school graduates, and 13 times more than that for college graduates.

Partly from prenatal smoking, low-income children are more likely to be born prematurely or with low birthweight and to suffer from cognitive problems; low birthweight babies, on average, have lower I.Q. scores and are more likely to have mild learning disabilities and attention disorders. Thirteen percent of black children are born with low birthweight, double the rate for whites. Even if all children benefited from equally high-quality instruction, this difference alone would ensure lower average achievement for blacks. Low birthweight is only partly caused by inadequate prenatal care, exposure to urban pollutants, diet, smoking and drinking. The interaction of poor health habits with other stresses exacerbates children’s adverse outcomes. Maternal stress has hormonal consequences that interfere with nutrient absorption on which healthy fetuses depend. Thus, low birthweight, alcohol consumption and smoking all have greater negative effects on poor children than on middle-class children who were exposed to similar risks. Poor women, with greater stress and less adequate nutrition, can tolerate less smoke and alcohol and still deliver healthy babies than women whose better overall health conditions protect their fetuses from effects of alcohol or smoking. Middle-class children more easily overcome earlier health shocks, rebounding when they later experience healthier environments after exposure to risk.

Poor nutrition
also contributes to achievement gaps between lower- and middle-class children. Even moderate under-nutrition affects academic performance, particularly if sustained. Iron deficiency anemia affects cognitive ability: 8 percent of all U.S. children, but 20 percent of black children, are iron-deficient. Anemia also makes it more probable that children will absorb lead to which they are exposed. Iron is but one ex
ample; compared to middle class children, the poor also lack other vitamins and minerals. In experiments where pupils got inexpensive vitamin and mineral supplements, test scores rose from that treatment alone.

Children without regular medical careare also more likely to contract other illnesses that keep them from school. Despite federal programs to make medical insurance available to low-income families, there remain gaps in access and utilization. Many eligible families are not enrolled because of ignorance, fear, or lack of conviction about medical care’s importance.

Thus, 19 percent of poor children are without consistent health insurance, compared to 11 percent of all children; 14 percent of black children are without insurance, compared to 7 percent of white children. These data were collected before the current economic crisis; conditions they describe are likely more severe today. Yet even with health insurance, parents’ low-wage work interferes with medical care utilization. Parents who are paid hourly wages lose income when they take children to doctors. Parents with blue-collar jobs risk discharge for excessive absence, so are likely to skip well-baby and routine pediatric care, seeing doctors only in emergencies. Salaried middle-class parents have more flexibility to schedule doctor visits, for themselves and their children, without loss of job or income.

Lower-class families with health insurance also confront huge disparities in medical facilities. A survey of one low-income minority Los Angeles neighborhood found one primary care physician for every 13,000 residents. A nearby high-income neighborhood had one for every 200 residents. Low-income families, with or without insurance, are more likely to use emergency rooms and less likely to use primary care doctors, even for routine care.

As a result, black pre-schoolers are one-third less likely than whites to get standard vaccinations for diphtheria, measles and influenza. There are also gaps between middle class and low-income children in optometric and dental care. Again, the problem is not only insurance, but access to routine and preventive care. Children covered by Medicaid are almost twice as likely to have untreated dental decay as children with private insurance.

Ongoing differences in regular pediatric care result in poor children losing many more days from school than the non-poor, on average. School attendance differences, attributable to disparities in health care access alone, cause differences between black and white children’s average achievement. Good teaching can’t do much for children who are not in school.

For these reasons, the health-related causes of low achievement are unlikely to be remedied without school-based clinics that provide routine and preventive pediatric, dental and vision care in schools serving disadvantaged children from kindergarten through the 12th grade. School-based clinics can provide routine and preventive care without the necessity of parents taking time off from work. School-based clinics, working cooperatively with school comprehensive service coordinators can also ensure that children are seen on a regular and recommended schedule for such care, without the necessity of parent initiative for appointments.


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