Impact of Chronic Illness Timing and Persistence

at School Entry on Child and Parent Outcomes:

Australian Longitudinal Study
Jon Quach, PhD; Tony Barnett, MSc
From the Royal Childrens Hospital Education Institute, Murdoch Childrens Research Institute, and The University of Melbourne, Parkville,
Victoria, Australia
The authors declare that they have no conflict of interest.
Address correspondence to Jon Quach, PhD, Centre for Community Child Health, Royal Childrens Hospital, Flemington Rd, Parkville 3056,
Victoria, Australia (e-mail: jon.quach@mcri.edu.au).
Received for publication December 20, 2013; accepted August 22, 2014.

ABSTRACT
OBJECTIVE: To understand the prevalence and timing of child
chronic illness at school entry; associations with child learning,
behavior and health-related quality of life and parent mental
health at ages 6 to 7, 8 to 9, and 10 to 11 years; and cumulative
health care costs.
METHODS: Data were drawn from the first 4 waves of the Longitudinal Study of Australian Children. Children were aged 4 to
5 years at wave 1, with data collection every 2 years. Parentreported timing of child chronic illness at school entry was categorized into 4 chronic illness groups based on changes between
waves 1 and 2: none, resolving, incident and persistent. Child
outcomes included: parent-reported quality of life, parent- and
teacher-reported behavior, teacher-reported child learning,
teacher-reported childteacher relationship, directly assessed
nonverbal and verbal cognition and parent self-reported mental
health. Linear regression, adjusted for gender and socioeconomic position, was used to quantify longitudinal associations
between chronic illness timing at school entry with outcomes
at age 6 to 7 years, 8 to 9 years and 10 to 11 years.

RESULTS: Of the 4983 children enrolled in the study, chronic

illness data was available for 4464 children (89.6%) at both
waves 1 and 2. From wave 1, 6.1% had a condition that persisted
until wave 2, while 14.1% had a condition that resolved.
Furthermore, 4.7% had a newly emerging condition at wave
2. Compared with the no chronic illness group, children with
persistent or emerging chronic illness during school entry had
the poorest outcomes (except fathers mental health) at all
time points, while children with resolving conditions had
smaller differences.
CONCLUSIONS: Child chronic illness at school entry is associated with poorer longitudinal child and maternal outcomes.
Therefore, future research should aim to determine the risk
and protective factors that contribute to the poorer child and
parent outcomes experienced in this growing population.
KEYWORDS: chronic illness; longitudinal; population-based
study; school entry
ACADEMIC PEDIATRICS 2015;15:8995

WHATS NEW

their parents are at increased risk of multiple stressors

related to uncertainty over the childs health outcomes,
daily hassles associated with medical regimens and
financial strain.9,10 Not surprisingly, there has been
increased focus in recent years on providing support for
these children during important transition periods, such as
starting elementary school.11,12
Children who have a poor transition to elementary
school are at greater risk of poorer academic pathways,
school completion rates and social and emotional development.11,12 A successful transition is not only
determined by the childs academic ability but also
additional factors such as their relationship with peers
and teachers,13 ability to participate in school activities,12 and support of their parents.14 Although these
factors can be influenced by the childs biology and
environment before starting school,15 they may also be
influenced by the childs health during the childs transition to elementary school.16 Therefore, children with
chronic illnesses during this period may be at greater

The timing and persistence of child chronic illness during the elementary school entry period is associated
with substantially poorer long-term child learning and
behavior, as well as maternal mental distress. Effects
are consistent up to the age of 10 to 11 years.

UP TO 30% of children in developed countries are reported

to have a chronic illness,1 with the prevalence increasing
over the past decade.2,3 Although different accepted
definitions of chronic illness have yielded differences in
prevalence rates in the United States and other developed
countries,2 it has been long accepted that a noncategorical
approach, independent of clinical diagnosis, is more appropriate and policy relevant to understand the consequences of
having a chronic illness.4,5 Research using this approach has
shown that children with chronic illnesses are at greater risk
of academic difficulties, increased absenteeism as well as
poorer social and emotional functioning.68 In addition,
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risk of poorer academic and social outcomes during

school entry and in later school years. Moreover, the
poorer outcomes may also extend to poorer parent
mental health and higher health care costs.
Furthermore, it is widely accepted that childrens
chronic illness can change over time. Therefore, it is
important to understand whether the emergence and persistence of chronic illness is associated with varying impact
on key child, teacher and parent indicators of short and
long-term child academic success and well-being.1114
This would inform those caring for these children as to
the medical and educational needs of these children,
taking into account their history of chronic illness.
We sought to address these current research gaps by using longitudinal data from a nationally representative
Australian population cohort. Specifically, we aimed to
determine: 1) The timing and persistence of chronic illness
from age 4-5 years (Wave 1) to 6-7 years (Wave 2), spanning the school entry period, and 2) The associations between categories of timing and persistence (i.e. absent,
resolved, incident and persistent) from Wave 1 to Wave 2
with:
a. Childrens learning, relationship with their teacher,
behavior, health-related quality of life and parent
mental health children at child age (a) 6-7 years, (b)
8-9 years and (c) 10- 11 years.
b. Cumulative health care costs between 4-5 to age 8-9
years.

METHODS
STUDY DESIGN AND SAMPLE
Data were drawn from the first 4, biennial waves of the
nationally representative Longitudinal Study of Australian
Children (LSAC). The sampling design and field methods
have been described elsewhere.17 Briefly, LSAC employed
a 2-stage cluster sampling design to recruit 2 independent
cohorts, the B cohort (recruited at 01 years) and the K
cohort (recruited at 45 years). In the first stage, postal codes (except the most remote) were sampled after stratifying
by state and urban versus rural status to ensure proportional
representation based on residential location. In the second
stage, all children born between March 1999 and February
2000 and enrolled in the Australian Medicare database, in
which 98% of all 4-year-old Australian children at the time
were registered, were eligible to be approached.
This study used data from the K cohort. Children were
randomly selected within each postal code to achieve a
cohort aged between 4.3 and 5.2 years at the wave 1 interview. All birth months were represented. Of the 10,596
children selected, 8,391 were still resident within that
postal code and could be contacted to be invited into the
study. Of these, 4,983 (59%) took part during 2004 and
the final sample had similar characteristics to the Australian population when compared to available census data
from the Australian Bureau of Statistics.17 The second
wave of LSAC took place during 2006; 4,464 of the
4,983 wave 1 children participated in wave 2 (89.6%). At

ACADEMIC PEDIATRICS

wave 4 in 2010 when the children were 10 to 11 years,

4103 (82%) remained in the study. No data are available
from the children who were no longer resident within
each postal code when recruitment commenced.
PROCEDURES AND INCLUSION CRITERIA
At both waves 1 and 2, trained researchers administered
a face-to-face interview in the childs home with the
primary caregiver, as well as brief direct assessments
with the children. In addition, written questionnaires
were completed by the primary and secondary caregiver
and, wherever possible, the childs elementary school
teacher. The study was approved by the Australian Institute
of Family Studies Ethics Committee, and a parent provided
written informed consent for every participant.
MEASURES
PREDICTOR MEASURES (CHILD CHRONIC ILLNESS; WAVES 1
AND 2)
In both waves, child chronic illness was defined by the
response to the following primary caregiver-reported question at interview: Does [Study Child] have any medical
conditions or disabilities that have lasted, or are likely to
last, for 6 months or more? The measure is directly
derived from the Disability Module used by the Australian
Bureau of Statistics to define children and adults with
chronic illness for national prevalence rates and to inform
federal policy in Australia.18 The broad definition is also
consistent with some previous definitions used in research
and policy in the United States.
For both aims, responses at waves 1 and 2 were combined to create the following 4 chronic illness groups: (i)
never (no chronic illness at either wave), (ii) resolved
(chronic illness at wave 1, but not at wave 2), (iii) incident
(chronic illness at wave 2, but not at wave 1), and (iv)
persistent (chronic illness at both waves). Creating groups
based on changes in chronic illness groups between the 2
waves recognizes that chronic illness can change over
time within the same population of children and have
dynamic differences in timing and persistence.19
OUTCOME MEASURES (WAVE 2, 3, AND 4)
Data from wave 2 were used to measure outcomes
during the school entry period when children were 6 to 7
years while wave 3 and 4 data measures the longitudinal
outcomes when children were 8 to 9 years and 10 to 11
years, respectively. Outcomes were selected based on a
review of the literature to measure a wide range of child,
teacher and parent indicators of short and long-term child
academic success and well-being.1114
Learning was assessed by the mean raw score of adapted
versions of the teacher-reported Language & Literacy (11
items) and the Mathematical Thinking (9 items) subscales
of the Academic Rating Scale from the Early Childhood
Longitudinal Study (ECLS).20 Each has a possible range
of 1 to 5, with higher scores indicating greater proficiency.
Approach to Learning was assessed by the mean scores
of the teacher-reported Approach to Learning subscale

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IMPACT OF CHRONIC ILLNESS TIMING AND PERSISTENCE

(6-items) from the Social Rating Scale used in Early Childhood Longitudinal Study-Kindergarten (ECLS-K).20 Items
were designed to assess various aspects of a childs
approach to learning, such as organization, working independently and task completion. The possible score range
was 1 to 6, with higher scores indicating better approaches
to learn.
The Wechsler Intelligence Scale for Children IVMatrix Reasoning subtest was directly administered as a
proxy for nonverbal cognition, with higher scores meaning better nonverbal cognition.21 As a proxy for verbal
cognition, receptive vocabulary was assessed using an
adapted, 40-item version of the Peabody Picture Vocabulary Test, with higher scores representing better verbal
cognition.22 Both these measures were only available
when children were 6 to 7 years (Wave 2).
Relationship with teacher was assessed using the
teacher-reported TeacherChild Relationship ScaleShort
Form (14 items). The possible score range was 28 to 75,
with higher scores representing a more positive relationship between the teacher and the child.23 The internal consistency for the Total Score is a 0.89.
Behavior was assessed by the parent-reported and
teacher-reported Strengths and Difficulties Questionnaire,
a 25-item validated measure of behavioral and emotional
problems for children aged 4 to 16 years;24 20 items
contribute to the Total Problems score used here (possible
range 0 to 40, with higher scores representing worse
behavior). The internal reliability of both measures was
high, with an a 0.82 for the parent reported version
and a 0.87 for the teacher reported.
Health-related quality of life was measured by the
parent-proxy Pediatric Quality of Life Inventory 4.0, a
23-item validated questionnaire for children aged 2 to 18
years with higher scores representing better quality of
life.25 It yields the 2 subscales of Psychosocial functioning
and Physical functioning, both having a possible range of
0 to 100 and a reliability of a 0.92.
Parent mental health was assessed by the self-reported
Kessler-6, which is a 6-item validated measure of mental
health distress, possible score range of 0 to 24, with higher
scores indicating greater psychological distress and the
measure had an internal consistency reliability a
0.89.26 Scores are available for mothers and fathers.
Health care costs for these children used linked data
from the Australian Medicare subsidized scheme.27
Through this system, the Australian federal government
subsidizes to a predetermined amount, the costs of visits
to non-hospital-based medical practitioners, diagnostic
and pathology services, treatments outside of public hospitals and pharmaceuticals for all Australian citizens. The
remainder of the cost, usually 15%, is paid by the patient.
The metrics reported in this paper represent the reimbursement for health care and medication costs provided
by the Australian federal government. Data for these children were available for 93% of the cohort for the period
between 4 to 5 years to 8 to 9 years. Costs are presented
in Australian dollars (August 2014, A$1 US$0.93)

91

COVARIATES
The following potential confounders measured at wave 2
were chosen a priori to be included in multivariable analyses: childs gender and family socioeconomic position.
STATISTICAL ANALYSIS
Analyses were conducted by Stata software, version
13.0 (StataCorp, College Station, Tex), using survey
methods to account for the unequal probability of participant selection into the sample, nonresponse and sample
attrition, and the multi-stage, clustered sampling design.28
Linear regression assumptions were checked and found to
be upheld.
Child and primary caregiver characteristics and the history of chronic conditions (aim 1) were described using
standard statistical summary measures.
Associations at each time point between the derived
chronic illness groups for the continuous child and parent
outcomes were determined using unadjusted and adjusted
linear regression to estimate the mean difference between
groups with the no chronic illness group as the reference.
Although the mean differences attenuated in the adjusted
regressions, there was little difference in our overall results. Therefore, only the adjusted regressions are presented in this paper. To enable interpretability and
comparison between the different measures and time
points, the mean differences are reported as effect sizes.
The presented P values are for the trend analysis, conducted in the direction of no, resolving, incident, and persistent
chronic illness.

RESULTS
STUDY CHARACTERISTICS
The Figure shows the flow through the study and Table 1
shows the sample characteristics. Chronic illness data were
available at waves 1 and 2 for 4464 children (89.6%).
Compared to children without chronic illnesses at either
wave, children with a chronic illness were more likely
male, have English as the main language at home, not in
a dual-parent family, and have a parent less likely to
have completed high school.
PREVALENCE OF CHRONIC ILLNESS (AIM 1)
In wave 1, 20.4% of parents reported their child had a
chronic illness and this decreased to 10.8% at wave 2.
Across the whole school entry period, 24.9% of children
had a chronic illness, with 6.1% having a persistent condition, 4.7% a new incident and 14.1% having a resolved
condition.
IMPACT OF CHRONIC ILLNESS STATUS OVER TIME (AIM 2)
The cross-sectional association between chronic illness
timing and persistence with outcomes during the school
transition period is shown in Table 2. In all measures except
for fathers mental health, the largest differences in scores
was for those with persistent problems (mean difference
range 0.42 to 0.81). The largest differences were for

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association between chronic illness timing and

persistence during school entry and child and parent
outcomes remained except for the association with
student-teacher closeness and conflict. The effect sizes
had a similar pattern to those when children were 6 to 7
years, with the persistent group having the largest effect
sizes, followed by the new incidence, resolving and then
no chronic illness groups. Furthermore, the largest differences were also for parent-reported child behavior, psychosocial functioning and teacher-reported child literacy.
HEALTH CARE COSTS ASSOCIATED WITH CHRONIC ILLNESS
DURING THE SCHOOL TRANSITION PERIOD (AIM 3)
Overall, children with a persistent condition had the
highest mean primary care medical costs per child
(A$1648, SE A$117) over the whole school transition
period, while costs were similar for those with new
($1196, SE $79) and resolving ($1151, SE $41)
chronic illness. Those with no chronic illness had the
lowest costs $681 (SE $12). These costs are aligned
with expecting health care burden, with the highest costs
being for children with persistent problems while lowest
costs for children without a chronic illness.

DISCUSSION
Figure. Study flow for the participants in the Longitudinal Study of
Australian Children.

parent-reported behavior (mean difference 0.81, 95% confidence interval [CI] 0.65 to 0.97), child psychosocial functioning (mean difference 0.80, 95% CI 0.97 to 0.62)
and teacher-reported child literacy (mean difference
0.75, 95% CI 0.91 to 0.58). In contrast, the outcomes
for children in the resolved group had the smallest effect
(mean difference range 0.00 to 0.23). Effect sizes for those
with a new condition were generally intermediate (mean
difference range 0.08 to 0.53) to those with resolving or
persistent problems.
In longitudinal analyses, the majority of associations
present at 6 to 7 years remained when children were 8
to 9 years and 10 to 11 years (Tables 3 and 4), the

Our study found that a quarter of Australian parents

reported that their child had a chronic illness during school
entry, with 6.1% having a persistent problem. Furthermore,
the timing and persistence of chronic illness was associated
with important learning and well-being outcomes for children, as well as mothers psychological stress and
well-being at every time point. The causal role of chronic
illness grouping was supported by temporal relationships,
with outcomes worsening according to whether childhood
chronic illness was never prevalent through to resolving,
incident or persistent.
This study makes an important contribution to the
current limited amount of empirical research in the area
of the prevalence and impact of childhood chronic illnesses. Specifically, it extends current research68 by
quantifying the longitudinal impact of chronic illness
during school entry on a wide range of child, teacher and

Table 1. Demographic Characteristics of Children and Parents

Chronic Illness Status
Characteristic
Child
n
Male, %
Age, mo, mean (SD)
Primary caregiver*
Age, y, mean (SD)
English main language spoken at home, %
Education status, %
Did not complete high school
Completed high school only
Completed tertiary/postgraduate degree
Dual-parent family, %

No

Resolving

Incident

Persistent

3356
47.5
81.9 (3.0)

627
57.9
81.8 (3.0)

209
66.5
81.9 (2.7)

272
65.4
81.8 (2.9)

35.0 (5.3)
84.0

34.4 (5.4)
88.3

34.7 (5.6)
87.0

34.3 (5.8)
93.3

43.4
33.2
23.4
85.3

39.2
31.1
29.7
86.1

49.6
30.9
19.5
83.1

35.9
32.7
31.4
88.1

*All measured at wave 1 except for age, which was measured at wave 2.

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IMPACT OF CHRONIC ILLNESS TIMING AND PERSISTENCE

93

Table 2. Adjusted Wave 2 Outcomes, When Children Are 6 to 7 Years Old, of Timing and Persistence of Illness During School Entry

Variable
Learning
Mathematics
Literacy
Approach to learning
Cognition
Nonverbal
Verbal
Childteacher relationship
Total score
Behavior
Parent report
Teacher report
Health-related quality of life
Psychosocial functioning
Physical functioning
Parent mental health
Mother
Father

No Chronic Illness,
Absolute Mean (SD)*
(n 3356)

Mean Differences Effect Size (95% CI) Compared to No Chronic

Illness Group
Resolving (n 627)

New Incident (n 209)

Persistent (n 272)

3.5 (0.8)
3.5 (0.7)
3.3 (0.7)

0.05 (0.16 to 0.05)

0.03 (0.14 to 0.07)
0.04 (0.13 to 0.06)

0.42 (0.59 to 0.24)

0.45 (0.63 to 0.28)
0.48 (0.66 to 0.30)

0.69 (0.85 to 0.52)

0.75 (0.91 to 0.58)
0.63 (0.79 to 0.47)

<.001
<.001
<.001

10.5 (3.0)
74.1 (5.0)

0.07 (0.16 to 0.02)

0.00 (0.1 to 0.10)

0.08 (0.21 to 0.05)

0.16 (0.32 to 0.00)

0.42 (0.58 to 0.26)

0.36 (0.50 to 0.23)

<.001
<.001

62.4 (6.6)

0.00 (0.09 to 0.10)

0.25 (0.47 to 0.04)

0.35 (0.50 to 0.19)

<.001

7.3 (4.6)
5.8 (5.3)

0.16 (0.07 to 0.24)

0.08 (0.01 to 0.18)

79.3 (12.7)
79.3 (12.7)

0.23 (0.34 to 0.12)

0.17 (0.28 to 0.06)

0.50 (0.68 to 0.31)

0.38 (0.59 to 0.17)

0.10 (0.00 to 0.20)

0.04 (0.16 to 0.08)

0.17 (0.03 to 0.36)

0.07 (0.25 to 0.11)

2.9 (3.2)
3.0 (3.1)

0.53 (0.35 to 0.70)

0.50 (0.30 to 0.69)

0.81 (0.65 to 0.97)

0.58 (0.42 to 0.74)

<.001
<.001

0.80 (0.97 to 0.62)

0.42 (0.59 to 0.24)

<.001
<.001

0.43 (0.27 to 0.60)

0.02 (0.19 to 0.23)

<.001
.8

CI indicates confidence interval.

*Chronic illness groups based on chronic illness prevalence from wave 1 to wave 2.
Adjusted for child gender and family socioeconomic position at wave 2. Trend analyses for outcomes in the direction of no, resolving, new
incident and persistent illness.

parent indicators of long-term child academic success and

well-being.1113 Furthermore, by taking into account the
dynamic nature of childhood chronic conditions over
time through our 4 groups,19 we highlight that the negative
associations on child, teacher and mother outcomes varied
depending on the timing and persistence of chronic illness
during the school entry period. Interestingly, we had a
higher prevalence of chronic illness at wave 1 compared
to wave 2, while previous research suggested higher prevalence rates in older children.10,19 These differences could
be a result of differing definitions and measures of chronic

illness,2 as well as variations in the prevalence rate of specific conditions between countries.1
This is the first study, to our knowledge, to examine the
history of child chronic illness during the important school
entry period using a nationally representative population.
Furthermore, it quantified the long-term impact of chronic
illness based on the timing and persistence of conditions
during the elementary school entry period. Its large sample
size and high retention rate support precise estimates of the
prevalence and history of chronic illness during this important period. In addition, use of the LSAC data enabled

Table 3. Adjusted Wave 3 Outcomes, When Children Are 8 to 9 Years Old, of Timing and Persistence of Illness During School Entry

Variable
Learning
Mathematics
Literacy
Approach to learning
Childteacher relationship
Total score
Behavior
Parent report
Teacher report
Health-related quality of life
Psychosocial functioning
Physical functioning
Parent mental health
Mother
Father

Mean Differences Effect Size (95% CI) Compared to No Chronic

Illness Group

No Chronic Illness,
Absolute Mean (SD)*
(n 3356)

Resolving (n 627)

New Incident (n 209)

Persistent (n 272)

3.6 (0.8)
3.6 (0.7)
3.3 (0.7)

0.14 (0.26 to 0.02)

0.08 (0.20 to 0.03)
0.11 (0.23 to 0.01)

0.52 (0.72 to 0.31)

0.45 (0.66 to 0.25)
0.36 (0.55 to 0.17)

0.53 (0.71 to 0.36)

0.65 (0.81 to 0.49)
0.45 (0.62 to 0.29)

<0.001
<0.001
<0.001

60.5 (7.6)

0.03 (0.14 to 0.07)

0.05 (0.25 to 0.14)

0.04 (0.21 to 0.13)

0.45

6.9 (4.8)
5.7 (5.5)

0.18 (0.07 to 0.28)

0.17 (0.06 to 0.29)

0.59 (0.38 to 0.80)

0.29 (0.12 to 0.46)

0.82 (0.64 to 1.01)

0.38 (0.21 to 0.55)

<0.001
<0.001

77.8 (12.8)
84.6 (13.6)

0.25 (0.37 to 0.14)

0.16 (0.27 to 0.05)

0.63 (0.81 to 0.44)

0.32 (0.52 to 0.12)

0.88 (1.06 to 0.71)

0.55 (0.75 to 0.35)

<0.001
<0.001

3.3 (3.4)
3.0 (3.2)

0.06 (0.06 to 0.18)

0.04 (0.10 to 0.18)

0.15 (0.04 to 0.34)

0.03 (0.21 to 0.27)

0.36 (0.16 to 0.56)

0.09 (0.13 to 0.30)

<0.001
0.34

CI indicates confidence interval.

*Chronic illness groups based on chronic illness prevalence from wave 1 to wave 2.
Adjusted for child gender and family socioeconomic position at wave 2. Trend analyses for outcomes in the direction of no, resolving, new
incident and persistent illness.

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Table 4. Adjusted Outcome at Wave 4, When Children Were 10 to 11 Years Old, of Timing and Persistence of Illness During School Entry

Variable
Learning
Mathematics
Literacy
Approach to learning
Childteacher relationship
Total score
Behavior
Parent report
Teacher report
Health-related quality of life
Psychosocial functioning
Physical functioning
Parent mental health
Mother
Father

Mean Differences Effect Size (95% CI) Compared to No Chronic

Illness Group

No Chronic Illness,
Absolute Mean (SD)*
(n 3356)

Resolving (n 627)

New Incident (n 209)

Persistent (n 272)

3.6 (0.8)
3.9 (0.7)
3.4 (0.7)

0.12 (0.24 to 0.01)

0.04 (0.15 to 0.08)
0.06 (0.17 to 0.05)

0.41 (0.58 to 0.23)

0.51 (0.69 to 0.34)
0.28 (0.47 to 0.10)

0.75 (0.93 to 0.56)

0.74 (0.92 to 0.56)
0.40 (0.56 to 0.25)

<.001
<.001
<.001

60.2 (7.2)

0.11 (0.21 to 0.00)

0.17 (0.39 to 0.05)

0.14 (0.30 to 0.03)

.01

7.2 (5.0)
5.0 (5.2)

0.23 (0.13 to 0.33)

0.20 (0.09 to 0.31)

0.53 (0.34 to 0.72)

0.32 (0.10 to 0.54)

0.90 (0.72 to 1.08)

0.59 (0.41 to 0.76)

<.001
<.001

78.3 (13.2)
80.5 (18.2)
3.1 (3.4)
2.5 (3.0)

0.22 (0.33 to 0.12)

0.11 (0.22 to 0.00)
0.11 (0.01 to 0.22)
0.03 (0.14 to 0.09)

0.49 (0.67 to 0.31)

0.28 (0.48 to 0.08)
0.37 (0.14 to 0.60)
0.07 (0.16 to 0.30)

0.80 (0.97 to 0.64)

0.43 (0.62 to 0.25)

<.001
<.001

0.37 (0.19 to 0.56)

0.14 (0.30 to 0.02)

<.001
.30

CI indicates confidence interval.

*Chronic illness groups based on chronic illness prevalence from wave 1 to wave 2.
Adjusted for child gender and family socioeconomic position at wave 2. Trend analyses for outcomes in the direction of no, resolving, new
incident and persistent illness.

examination of the adverse effects of chronic illness on a

diverse range of outcomes using validated measures.
This study had some limitations. First, the LSAC-defined
measure of chronic illness was any condition lasting more
than 6 months and therefore not condition specific. Although
this definition is used by the Australian government and is
similar to accepted definitions used in previous research,2
we acknowledge that there are several accepted definitions
used in research and policy that can lead to variations in reported prevalence rates.2 However, this noncategorical
approach is directly relevant to health and education policy,1,35 given policies in these areas are often developed at
the population-level with the expectation that health and education services would adapt or individualize responses to
meet each childs specific illnesses needs. It is also likely that
the differences in some of our outcomes could be affected by
specific conditions, such as children with cognitive delay
increasing our reported differences for child learning outcomes. Second, chronic illness was measured using parentreport rather than medical records, which may lead to bias
if parents chose not to disclose a childs condition or did
not perceive the condition to be a chronic illness or disability.
Due to a lack of a national electronic medical system, it was
not feasible to verify parent-report with the childs medical
records. Third, this study examined chronic illness reported
during the school entry period and is unable to address the
impact of chronic illness during the preschool years or in
the proceeding period after school entry. However, the latter
will be able to be explored with subsequent data releases
from the LSAC cohort as well as impact on other important
school transition periods such as the transition to middle
school.
The common prevalence and long-term associations of
chronic illness during school entry highlight the need to
better understand what support these children need during
this important period. Ensuring that each child has the right
to achieve their full potential should be seen as a public

health equity issue by both the education and health sectors,29 and an opportunity to have an integrated and collaborative early intervention approach for children with
chronic illness.30 This would entail clear and continued
communication between the childs medical home (ie, their
pediatrician) and the childs school to ensure the support
the child is receiving from both sectors meets the childs
current health and educational needs. The additional challenges for education and health services are the need to be
attuned to childrens developmental stage, their dependence on parents and schools and the different types and
patterns of chronic illness across the school entry period.
To gain a better understanding of what areas interventions should target, future research should investigate the
modifiable risk and protective factors present during the
early school years that affect child long-term academic
and health outcomes for children with chronic illnesses.
However, some areas of potential intervention have been
previously identified. One area could be the education
and improvement in pediatrician practice to better integrate
individualized education plans as part of the medical home
for children with chronic illnesses.31 In particular, understanding the childs educational needs during periods of
school absenteeism due to their illness through hospitalization or home care, and their reentry to school after extended
leave. This may be particularly important in light of the
recent findings by Willits et al,32 who suggested that
improved health care alone does not necessarily reduce
absenteeism for children with chronic illness. Another
area could be providing these children with experiences
that increase their confidence and motivation to achieve,
and exposure to experiences that promote positive peer
and teacher relationships.33 Improving health literacy
about child chronic illness may also be beneficial by
increasing parent and school awareness of the childs needs
beyond their illness alone.34 In addition, support around the
childs comorbidities such as their social and emotional

ACADEMIC PEDIATRICS

IMPACT OF CHRONIC ILLNESS TIMING AND PERSISTENCE

well-being or support for parents may also yield important

positive benefits.35 Future research should focus on understanding the risk and protective factors that predict poorer
outcomes for children with chronic illness to understand
the extent to which these types of interventions could
improve child and parent outcomes.

CONCLUSIONS
About a quarter of Australian children entering school
have a chronic illness, and the timing and persistence of these
conditions are associated with poorer child and parent outcomes at the population level during the school entry period
and in later years. Future studies should focus on understanding the risk and protective factors that could be targeted in
population and individualized interventions to improve
both short- and longer-term health and educational outcomes
for these children, as well as their parents mental health.
ACKNOWLEDGMENTS
This article uses confidentialized unit record files from the Longitudinal
Study of Australian Children (LSAC) survey. The LSAC project was
initiated and is funded by the Commonwealth Department of Families,
Housing, Community Services and Indigenous Affairs (FaHCSIA) and
is managed by the Australian Institute of Family Studies. The findings
and views reported herein, however, are those of the authors and should
not be attributed to either FaHCSIA or the Australian Institute of
Family Studies. We thank all the parents and children who took part
in the Longitudinal Study of Australian Children (http://www.
growingupinaustralia.gov.au/). Research at The Royal Childrens Hospital
Education Institute is funded by the Victorian Department of Education
and Early Childhood Development. Research at the Murdoch Childrens
Research Institute is supported by the Victorian governments Operational
Infrastructure Program. Dr Quach is supported by an Australian Research
Council Discovery Early Career Research Award (DE140100751).

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