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Learning, School Performance, and Children with Asthma: How Much at Risk?
Marianne P. Celano and Robert J. Geller
J Learn Disabil 1993 26: 23
DOI: 10.1177/002221949302600103

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 Learning, School Performance,
and Children with Asthma:
How Much at Risk?

Marianne P. Celano and Robert J. Geller

Children with asthma may be at risk for decreased school functioning due to acute exacer- ness in childhood to be associated with
bations, increased absenteeism, iatrogenic effects of their asthma medication, and the stress poor psychological adjustment (Cad-
associated with a chronic illness. The purpose of this article is to critically review extant man, Boyle, Szatmari, & Offord, 1987;
research pertaining to the school functioning of children with asthma, including studies of Orr, Weller, Satterwhite, & Pless,
school attendance, school performance, the effects of asthma medications on learning and 1984), though several authors have
behavior, and the role of psychological variables in the development of functional impairments.
questioned both the existence and
There is not sufficient evidence to suggest that children with asthma are at significantly higher
the meaning of such a relationship
risk for poor school performance than children without asthma. Factors that may contribute to
poor school performance among children with asthma include iatrogenic effects of oral steroids, (Moran, 1991; Stein & Jessop, 1984).
poor medical management of the disease, and psychological problems. Recommendations for Although a burgeoning literature ad-
improving the school functioning of children with asthma are discussed. dresses the psychosocial impairments
of children with asthma, very few in-
vestigators have specifically examined
the impact of asthma on behaviors re-

A
sthma is one of the most
chronic illnesses found in chil-
dren. Recent population stud-
ies of children with asthma yield
prevalence estimates from 6.7% to 12%
(Burr, Butland, King, & Vaughan-
Williams, 1989; Gergen, Mullally, &
Evans, 1988), with significantly higher
prevalence rates among blacks than
whites (Gergen et al., 1988; Schwartz,
Gold, Dockery, Weiss, & Speizer,
1990). The prevalence (Burr et al., 1989;
Fulwood, Parker, & Hurd, 1990; Ger-
gen et al., 1988), morbidity (Gergen &
Weiss, 1990), and mortality (Evans
et al., 1987) of childhood asthma have
been increasing since the early 1970s.
Both physiologic and psychological
risk factors associated with asthma
mortality have been identified, includ-
ing (a) depressive symptoms, (b) his-
tory of seizures associated with an
asthma attack, (c) disregard or denial
of asthmatic symptoms, (d) substantial
decrease in prednisone dosage during
hospitalization, (e) unsupportive fam-
ily, and (f) conflict between the pa-
tient's parent and hospital staff re-
garding medical management (Fritz,
Rubinstein, & Lewiston, 1987; Strunk,
Mrazek, Fuhrmann, & LaBrecque,
1985).
Children with asthma may suffer
from a variety of functional impair-
ments, depending on the severity and
nature of their illness. Acute exacer-
bations of symptoms (e.g., wheezing
and coughing) may lead to bed rest, re-
stricted physical activity, and/or school
absence, whereas chronic manifesta-
tions of the illness (e.g., shortness of
breath and airway hyperreactivity)
may result in impaired physical condi-
tioning (Ludwick, Jones, Jones, Fuku-
hara, & Strunk, 1986) and avoidance
of certain foods or social activities. Like
children with other chronic illnesses,
children with asthma are at risk for
psychosocial difficulties. Epidemio-
logical studies have found chronic ill-
lated to school functioning, such as
learning, memory, attendance, con-
centration, and academic achievement.
Children with asthma may be at risk
for school failure due to their symp-
toms, functional impairments (includ-
ing school absenteeism), and/or iatro-
genic effects of treatment. The purpose
of the present article is to critically
review extant research pertaining to
the school functioning of children with
asthma, and to make recommenda-
tions to enhance their academic per-
formance.
Pathophysiology of Asthma
Many years ago, asthma was under-
stood to be a problem of airway con-
striction caused by airway hyperreac-
tivity to various stimuli. These stimuli
could be external to the patient (extrin-
sic asthma), including pollens, weather
change, and exercise. Alternatively,

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VOLUME 26, NUMBER 1, JANUARY 1993
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PAGES 23-32
24 JOURNAL OF LEARNING DISABILITIES

the patient could be displaying bron- the role of bronchodilating agents; (Godfrey, Balfour-Lynn, & Konig,
chial obstruction because of his or her however, the early use of mast cell 1975; Hoag & McFadden, 1991; Silver-
own overresponse to otherwise mild stabilizers and anti-inflammatory man, Connolly, Balfour-Lynn, & God-
irritants (intrinsic asthma). agents is increasingly recommended to frey, 1972). Cromolyn is the only mast
The pathophysiology of asthma is control the LAR and BHR. Combina- cell stabilizer currently approved for
currently considered to be more com- tion therapy with both bronchodilators use in the United States, and it has no
plex (for recent reviews, see Church, and anti-inflammatory agents and/or significant side effects, according to
1989, and Konig, 1987). We now recog- mast cell stabilizers is now widely used published clinical studies. Cromolyn
nize asthma to be the culmination of for the treatment of moderate to severe must be administered by inhalation,
several processes: bronchial obstruction, asthma. This provides inhibition of all either from a hand-held, metered-
bronchial and pulmonary inflammation, three phases of asthma. dose inhaler (MDI) or from an external
and increased bronchial and pulmo- Beta2-adrenergic agonists have compressed-air-driven nebulizer.
nary mucoid secretions. gained wide recognition for their po- Cromolyn use is sometimes limited by
Bronchial obstruction may be pre- tent and prompt bronchodilating prop- administration considerations: Young-
cipitated by exercise, weather changes erties. This bronchodilation relieves er patients lack sufficient coordination
(particularly cold air), upper respir- the symptoms of the EAR but does not to use an MDI, and compressed-air
atory infections, or exposure to a sub- address the later phases of disease. nebulizers are both bulky and more
stance (e.g., specific pollen or food). Muscle tremor and a stimulant sen- expensive.
The initial bronchial response, called sation have been noted with these Corticosteroids were introduced for
the "early asthmatic response" (EAR), agents, though their extent varies treatment of asthma almost 40 years
occurs within 30 minutes and lasts up widely among individuals. ago. Initially, steroids were adminis-
to 2 hours. During this period, inflam- Theophylline is a bronchodilator, tered systemically, thereby exposing all
matory cells are released into the air- chemically related to caffeine, that has body tissues to drug effects. As corti-
ways, injuring lung tissue and re- been widely used for many years. This costeroid preparations have been re-
sulting in one or more subsequent agent also addresses the bronchial ob- fined, some of the adverse effects ini-
episodes of air flow reduction—"late struction characteristic of the EAR, but tially encountered have been reduced.
asthmatic response" (LAR). These is less potent at doing so than the Nevertheless, significant potential for
events also predispose the patient to jS2-agonists. Theophylline, however, is adverse effects exists even with state-
increased susceptibility to irritants widely thought to suppress LAR and of-the-art steroids administered sys-
(a state called "bronchial hyper- also to reduce BHR; therefore, it is par- temically. Adverse effects commonly
responsiveness," or BHR), ultimately ticularly useful when combined with experienced include reductions in the
resulting in further inflammation and aerosol corticosteroids (Church, 1989; body's ability to handle physiologic
bronchoconstriction. Cockcroft, Murdock, Gore, O'Byrne, & stress and fight off infection, impaired
The debris created by the tissue in- Manning, 1989; Pauwels, van Renterg- linear growth, altered bone minerali-
jury and the local response to this hem, van der Straeten, Johannesson, zation, and changes in facial appear-
event contribute to collection of & Persson, 1985; Weinberger & Hen- ance. Less common effects include
thicker-than-usual secretions. These deles, 1986). At desired serum concen- high blood pressure, elevated blood
secretions facilitate the plugging of trations, upset stomach and/or a stim- glucose, memory deficits, and psy-
small airways and obstruction of air- ulant sensation may be described, chiatric symptoms, ranging from mild
flow to and from the sites of gas ex- depending on individual sensitivity. depressive symptoms to psychosis.
change in the lungs. Airway obstruc- When serum concentrations of the- Within the last 15 years, the deliv-
tion may lead to collapse of entire areas ophylline become excessive, stomach ery of corticosteroid agents directly to
of the lung, further impeding gas discomfort, seizures, and/or cardiac the affected area has been developed,
transfer and increasing the work of rhythm disturbances may occur. Be- with the goal of reducing undesired
breathing. cause of this potential toxicity and the side effects while still retaining effi-
wide variation in doses necessary for cacy. Several agents are available in
effective yet safe treatment, theophyl- the United States for administration
Clinical Pharmacology of line is now less extensively used than via MDI: Beclomethasone (e.g., Beclo-
Asthma Therapy it was a decade ago. vent®, Vanceril®), flunisolide (e.g.,
Mast cell stabilizers have gained in- AeroBid®), and triamcinolone (e.g.,
The pharmacologic therapy general- creasing acceptance in the chronic ther- Azmacort®) are among the most wide-
ly used for asthma has changed as our apy of asthma. By reducing the airway ly used. These agents, administered
conception of the underlying patho- and pulmonary response to irritant directly to lung tissue, appear to be
physiology has evolved. Initial at- stimuli, the inflammation and bron- free of many of the serious adverse ef-
tempts at treating asthma emphasized choconstriction may be ameliorated fects associated with systemic steroid

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use, with the remaining adverse effects
occurring at lesser severity.
School Attendance
Like other children with chronic ill-
nesses, children with asthma miss sig-
nificantly more school than their
healthy peers (Parcel, Gilman, Nader,
& Bunce, 1979). However, there is not
sufficient evidence to suggest that
school absence rates are associated
with severity of disease. Although
Parcel and his colleagues found rates
of absence to be positively related to
maternal perceptions of symptom se-
verity, later studies of children with
asthma (Gutstadt et al., 1989) and
other chronic illnesses (Stein & Jessop,
1984; Weitzman, Walker, & Gort-
maker, 1986) did not find any relation-
ship between illness severity and
school absence. These discrepant find-
ings may be attributed to different
means of assessing absence rates and
different definitions of illness severity,
as well as to the use of different sets
of predictor variables.
School absence among children with
chronic illness reflects a variety of
health-related and non-health-related
factors (Weitzman, 1986). Increased ab-
sence among children with chronic ill-
ness has been found to be related to
the child's reported psychosocial prob-
lems (Stein & Jessop, 1984; Weitzman
et al., 1986) and to the combination of
female gender, increased clinic visits,
physician's rating of greater activity
limitation, and specific health con-
ditions (Fowler, Johnson, & Atkin-
son, 1985). Low socioeconomic status
(SES), which is associated with school
absence among general school popu-
lations (e.g., Boardman, Byzanski, &
Cottrell, 1975), does not appear to
predict absence among children with
chronic illness (Fowler et al., 1985).
Although further research is needed to
determine the effects on school ab-
sence of other factors (e.g., school
attended, mental health problems
among family members), the literature
suggests that children with chronic ill-
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VOLUME 26, NUMBER 1, JANUARY 1993
ness are at increased risk for school ab-
sence in part because of illness-related
factors. Chronically ill children who are
most likely to be absent from school are
those with psychosocial problems, fre-
quent visits to the doctor, and/or
symptoms that restrict their activity.
School Performance
Children with asthma may be at risk
for decreased school performance for
a number of reasons, including (a) in-
creased absenteeism, (b) iatrogenic ef-
fects of asthma medication, (c) teach-
ers' or parents' perception that the
child is too vulnerable to participate in
certain school activities, (d) acute ex-
acerbations of symptoms, and (e) stress
associated with a chronic illness. Ac-
cording to a stress and coping model
(Rutter, 1983), the child's illness and/or
treatment regimen constitute stressors
that may overwhelm his or her intra-
personal and environmental resources
and result in adverse psychosocial
outcomes. Decreased psychosocial
functioning may be manifested in be-
havioral problems, poor peer relation-
ships, parent-child conflict, and/or
diminished academic performance. As
the effects of stress are mediated in
part by characteristics of the individ-
ual and his or her social environment,
there is great variability in the ways in
which children cope with the stress
posed by their asthma.
There have been relatively few
studies of the relationship between
asthma and school performance. In an
early study, Freudenberg et al. (1980)
interviewed 200 urban, low income
parents about their asthmatic chil-
dren's school functioning. Approxi-
mately 40% of the parents indicated
that their child had difficulty in school,
particularly in reading. Standardized
achievement tests were not adminis-
tered to validate parental reports of
reading difficulty, and the relationship
between asthma severity and school
performance was not assessed. The
lack of a control group and incomplete
information about the medical history
25
of the sample further limit interpreta-
tion of these findings. Freudenberg
et al.'s report of decreased school per-
formance among children with asthma
has not been supported by studies that
utilized a control group (McLoughlin
et al., 1983; Silva et al., 1987) or stan-
dardized tests of intelligence and aca-
demic achievement (Gutstadt et al.,
1989; Silva et al., 1987). These dis-
crepancies may reflect the considerable
variability in frequency and severity of
asthma symptoms. Diminished school
performance may be due not to a diag-
nosis of asthma, but to illness severity
or duration and medication use.
Gutstadt et al. (1989) sought to de-
termine the impact of these factors on
academic performance among a sam-
ple of 99 children admitted to the
hospital for treatment of severe, chron-
ic asthma. Hypothesized independent
variables were entered into a stepwise
regression analysis in the following
order: SES and school absence, medi-
cal variables, and behavior problems.
Results indicate that SES, history of
oral steroid use in the preceding year,
age, and total behavior problems (as
measured by the Child Behavior
Checklist, CBC) accounted for a third
of the variance in reading scores and
mathematics scores. That is, low per-
formance was associated with low
SES, continuous use of oral steroids
(either prednisone or methylpredniso-
lone) at least every other day for the
year prior to evaluation, older age, and
greater behavioral problems. School
absenteeism in the semester prior to
evaluation, which ranged from 0% to
94%, did not correlate with academic
performance.
Gutstadt et al.'s (1989) findings are
consistent with the results of a larger
study of children with chronic illness
(Fowler et al., 1985). Fowler et al.'s
sample consisted of 270 children with
chronic health conditions, including
arthritis, cystic fibrosis, diabetes, epi-
lepsy, hemophilia, sickle cell disease,
spina bifida, and chronic lung disease
(e.g., asthma). School achievement (as
measured by the California Achieve-
ment Test) was predicted by race, SES,
26 JOURNAL OF LEARNING DISABILITIES

number of children in the family, his- brain damage that may result from leagues (Bender, Belleau, Fukuhara,
tory of grade failure, and specific health undertreatment of severe asthma (e.g., Mrazek, & Strunk, 1987) did not find
conditions; these factors collectively ac- Bierman, Pierson, Shapiro, & Simons, evidence of impaired neuromotor func-
counted for 44% of the variance in test 1975). tioning among a sample of 67 children
scores. Children who scored lower Dunleavy and Baade (1980) assessed with severe asthma. The absence of
tended to be nonwhite, to come from brain damage-related cognitive and significant impairment is even more
lower SES backgrounds, and to have behavioral deficits in 19 children with striking given that their sample con-
epilepsy, sickle cell disease, or spina severe asthma and in a matched con- sisted of children considered to be at
bifida. School absence was not related trol group. The children with asthma increased risk for neuromotor impair-
to academic achievement, in contrast obtained significantly lower scores ment due to diminished academic
to state data indicating a correlation be- than the control group on 8 of the 36 skills or observed motor awkwardness.
tween increased absence and lower tests of the Halstead Neuropsycholog- The discrepancy between these two
achievement for the general school ical Test Battery for Children. Using a sets of findings may be due to the use
population (Fowler et al., 1985). Fowler statistical classification scheme validat- of different assessment techniques.
et al. did not assess behavior problems ed by a neuropsychologist's blind clin- Bender et al. used the Bruininks-
among their sample. ical analyses, the authors identified 7 Oseretsky Test of Motor Proficiency,
The preceding studies suggest that (37%) of the 19 asthmatic children and whereas Dunleavy and Baade used the
academic performance among children 1 of the 19 control children as neuro- Halstead Neuropsychological Test Bat-
with severe asthma is likely to be in- psychologically impaired. The neuro- tery; Bender et al.'s conclusions are
fluenced by SES and behavior prob- psychological deficits of the asthmatic therefore limited to only one dimen-
lems, and not by school absence. Even children were mild and consisted pri- sion of neuropsychological func-
children without chronic illness are marily of difficulties in incidental mem- tioning.
likely to fare poorly in school if they ory, in visualizing and recalling spatial Bender et al. (1987) specifically ad-
come from low SES backgrounds or ex- configurations, and in planning and dressed Dunleavy and Baade's (1980)
hibit behavior problems that interfere executing visual and tactile motor hypothesis that neuropsychological im-
with their learning (e.g., Hinckley, tasks. Dunleavy and Baade concluded pairment may reflect brain damage sus-
1979). However, the lack of a relation- that episodes of transient hypoxemia tained during severe hypoxic attacks.
ship between school absence and per- associated with severe asthma attacks They found no association between
formance among children with asthma can cause brain abnormalities in chil- respiratory failure and neurologic ab-
and other chronic illnesses is at vari- dren. normalities (as assessed by clinical
ance with previous reports of the gen- Suess and Chai (1981) questioned exam), nor did they find significant
eral school population (e.g., Roberts, Dunleavy and Baade's (1980) conclu- relationships between neuromotor
Basco, Slome, Glasser, & Handy, sions, and suggested that antiasthma functioning and history of seizures or
1969), suggesting that (a) absence for medications such as theophylline and respiratory failure, abnormal neuro-
chronically ill children is related pri- corticosteroids may account for the logic signs, use of oral steroids, age of
marily to illness rather than psycho- observed neuropsychological impair- asthma onset, pulmonary-function test
social factors, and/or (b) the effects ment. Dunleavy (1981) responded with results, or number of asthma-related
of absence on achievement over and additional data indicating that drug hospitalizations in the previous year.
above those of SES are insignificant. usage and neuropsychological test per- Significant correlations were found
The specific role of illness factors in formance were not related in his sam- only for two measures of psychosocial
children's academic achievement re- ple, though he did not report any in- functioning. Lower gross motor and
mains controversial. Gutstadt et al. formation on the severity and duration battery composite scores were moder-
(1989) identified several illness factors of hypoxemia. In addition, a substan- ately associated with decreased psy-
that predicted poor achievement in tial number of his "severely asth- chosocial functioning as measured by
their sample, including early onset and matic" subjects were not receiving the Children's Global Assessment
longer duration of asthma (reflected in asthma medication, raising questions Scale and the Family Global Assess-
the correlation between age and per- about the generalizability of his find- ment Scale. Bender et al. suggested
formance) and use of oral steroids. ings. In summary, the Dunleavy and that children with poor psychosocial
Both of these factors contributed to Baade study suggests a possible organ- functioning are at risk for neuromotor
performance deficits over and above ic basis for cognitive deficits among problems due to their physical inactivi-
the impact of SES. However, Gutstadt children with asthma but does not pro- ty, social withdrawal, decreased school
et al. found no relationship between vide sufficient data to support this attendance, and lack of family support
performance and illness severity. De- hypothesis. for motor development.
creased school performance may also In contrast to Dunleavy and Baade's In summary, the more rigorous em-
be due to the hypoxemia-induced (1980) findings, Bender and his col- pirical studies indicate that children

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 VOLUME 26, NUMBER 1, JANUARY 1993 27

with severe asthma do not significant- who had received corticosteroids for age 74 mg/day) to their own perfor-
ly differ in their school performance varying disorders, 48 for "allergic" mance during chronic lower dose ther-
from children without asthma, despite conditions. The specific corticosteroid apy (average 22 mg/day). Depression
their greater absenteeism. School ab- preparations used, the doses em- and anxiety, as measured by the Be-
sence does not appear to be related to ployed, and the medications in con- havioral Test Battery, were more com-
achievement for children with asthma current use were not mentioned. mon while the children were receiving
or other chronic illness. Decreased According to de la Riva's assessment, the higher dose of medication. How-
school performance among children corticosteroids had adverse effects on ever, because the higher dose was ad-
with asthma is likely to be due to behavior and/or mood for 34 children. ministered for flare-ups of asthma, the
(a) low SES, (b) behavior problems, "Euphoric dysthymias" were reported exacerbation itself may have contrib-
and/or (c) illness factors. Socioeco- in 14, and "depressive states" in 20. uted to the changes in affect.
nomic status appears to be the most The euphoric-dysthymia group includ- An elaboration of the 1987 Lerner
significant predictor of performance. ed children with restlessness, irritabil- and Bender (cited in Satel, 1990) study
Although the importance of any one ity, "premature sexual impulses," or resulted in one of the best analyses to
illness factor remains unclear from the "homosexuality." The depressive- date regarding steroids and learning in
limited research done to date, the data state group included children with in- children with asthma (Bender, Lerner,
suggest that decreased performance somnia, "incapability for concentra- & Kollasch, 1988). The authors com-
may be due to iatrogenic effects of cor- tion," or apathy. Criteria for these pared the performance of 27 children
ticosteroids and cannot be attributed to diagnoses were not reported. The limi- when receiving daily prednisone doses
hypoxemia-induced brain damage. tations of this study, including the use (low doses of 2 to 10 mg/day, mean 3.3
Proposed associations between asthma of outdated psychiatric models and the mg/day) to those children's perfor-
severity and decreased performance subjective opinion of one psychiatrist mance after receiving acute increases
have not been supported by the data, as the diagnostic endpoint, are suffi- in prednisone doses (high doses of 40
perhaps because of the multiple and ciently severe to preclude extrapolation to 80 mg/day, mean 61.5 mg/day) be-
conflicting ways in which severity has from these data. cause of disease exacerbations. All sub-
been defined. A study of 38 hospitalized children jects were evaluated with multiple
with asthma compared those receiving standardized instruments after their
theophylline and prednisone to those disease had stabilized; half were stud-
Drug Effects on Learning receiving only theophylline (Suess, ied first at low dose, and half were
Stump, Chai, & Kalisker, 1986). Chil- studied first at high dose. The contri-
The effects of various agents used in dren taking both medications were bution of concomitant medications was
the treatment of asthma have been found to have impaired verbal memory examined; no association was found.
evaluated to varying degrees. (32- 8 hours after initiation of therapy, but The high-dose prednisone group ex-
adrenergic bronchodilators have not beenthe difference was no longer apparent hibited subtle reductions in recall abil-
examined in published studies specif- by the next day. ity and displayed more anxiety and de-
ically addressing their possible effects Lerner and associates carried out a pressive symptoms, but did not show
on school performance. Mast cell sta- series of controlled studies on the ef- attention deficits or increases in hyper-
bilizers have been evaluated in three fects of prednisone on children with active behavior. These findings were
double-blind studies comparing theo- asthma (Lerner, Mrazek, & Strunk, as interpreted by the authors as being
phylline with cromolyn sodium for the cited in Satel, 1990). Among a sample consistent with those of Suess et al.
treatment of mild to moderate asthma. of 36 children, they found that the (1986). In conclusion, systemic gluco-
These studies are reviewed in the sec- group receiving daily oral prednisone, corticoids may exert subtle influences
tion on theophylline. 20 mg/day (a typical dose for control on memory and mood in a dose-
of severe asthma), were "five times dependent manner, with higher doses
more likely to develop depressive and associated with more adverse effects.
Corticosteroids anxious complaints" (p. 14) than those
Several studies have been published not receiving steroids. Symptoms were
Theophylline
that address the effects of corticoster- assessed using the Children's Behavior
oids on learning, mood, or behavior. Checklist. Details of the case-control Many studies have attempted to
All have significant methodologic limi- matching were not available. assess the relationship between the-
tations. Perhaps the first discussion of In another study by Lerner and asso- ophylline use and learning-related be-
the effects of childhood oral steroid ciates (Lerner & Bender, as cited in haviors. This topic is fraught with dif-
therapy on mood and behavior was Satel, 1990), eight asthmatic children ficulty, given the need to control the
that of de la Riva (1958). De la Riva were compared during short-term, dietary intake of related compounds
reported a case series of 55 children high-dose prednisone therapy (aver- (e.g., caffeine), preexisting medical

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28
and/or psychiatric conditions, the pos-
sibility of adaptation to theophylline
over time, school performance, and so-
cioeconomic status. No studies have
succeeded in controlling all of these
variables. For a fuller discussion of
these difficulties, see Creer and Gus-
tafson (1989) and Weinberger, Lind-
gren, Bender, Lerner, and Szefler
(1987).
The possibility of an association be-
tween theophylline and school behav-
ior problems was first raised by the
double-blind study of cromolyn versus
theophylline conducted by Furukawa
et al. (1984). For a sample of 18 children
on theophylline, Furukawa et al. re-
ceived "spontaneous" reports of
"school behavior problems" for 1 child
after 1 week of medication use and for
2 children after 2 months of use, but
no reports in a sample of 22 children
taking cromolyn sodium. Neither
teacher observations nor standardized
measurements of school performance
were utilized. In another double-blind
comparison of cromolyn versus the-
ophylline (Springer, Goldenberg, Ben-
Dov, & Godfrey, 1985), 13 children
were evaluated during the third week
of a 1-month medication period, then
were crossed over to the other medi-
cation and reevaluated after 3 weeks.
Theophylline levels in serum were fol-
lowed and maintained at an appropri-
ate value. Using a battery of stan-
dardized tests, Springer et al. found
better visual-spatial planning for the
four children with average IQ scores
when receiving cromolyn. This differ-
ence was not present for the nine chil-
dren with above-average IQ scores. A
placebo period was not used, prevent-
ing comparison of cromolyn effects
with a baseline drug-free state.
A study of 29 asthmatic children
(Furukawa et al., 1988) was under-
taken to compare theophylline against
cromolyn in more detail. All children
started on theophylline, and in mid-
course half were switched to cromolyn.
The children were assessed with the
Wechsler Intelligence Scale for Chil-
dren-Revised, the Selective Remind-
JOURNAL OF LEARNING DISABILITIES
ing Test, the Benton Visual Retention
Test, the Stroop Test I and II, and the
Child Behavior Checklist. Memory and
concentration improved, and depres-
sive and anxiety symptoms abated in
the group switched to cromolyn.
A randomized, double-blind, cross-
over study of 18 adolescents and adults
compared theophylline to albuterol
(Joad, Ahrens, Lindgren, & Weinber-
ger, 1986). Eight of the 18 were also on
inhaled beclomethasone, a cortico-
steroid, throughout the study, and 1
was on oral prednisone (30 mg taken
every other day). Global impressions
and patient diaries showed no differ-
ence in adverse effects, but a struc-
tured questionnaire revealed a signifi-
cant increase in depressive symptoms
while patients were receiving the-
ophylline. Psychological testing re-
vealed significantly improved verbal
learning for the group receiving the-
ophylline, as measured by the Serial
Digit Learning Test. Both effects, how-
ever, were of such small magnitude
that the authors question their clinical
relevance.
In a controversial study of the effects
of theophylline on learning, Rachel-
efsky et al. (1986) compared theophyl-
line to placebo for 20 children with
mild asthma. The children's behavior
was assessed with psychological tests
and parental and teacher reports on
standardized forms. Theophylline lev-
els were maintained in the desired
therapeutic range. Seven children
were noted to have poorer scores re-
garding behavior-attention while on
theophylline, while no children had
worse scores while on placebo. How-
ever, the effect of theophylline on be-
havior was not detected by parents,
and measures of academic perfor-
mance were not used. Furthermore,
the authors' method for maintaining
theophylline levels in the desired
range entailed drawing blood from
the children during the treatment
phase of the study but not during
the placebo phase, possibly destroy-
ing the double-blinded nature of the
study.
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The two most recent projects com-
paring theophylline effects on learning
with placebo found no differences
between treatment groups. Rappaport
et al. (1989) studied 17 asthmatic chil-
dren of normal intelligence. A double-
blind crossover design was employed
after an initial period to determine the
appropriate dose of theophylline for
each subject. Patients were assessed
after 2-week periods of either drug or
placebo. Twenty-seven different vari-
ables, including measures of perfor-
mance, behavior, and attention, were
analyzed. Only one variable showed a
theophylline effect, and another mea-
sure of the same variable showed no
effect. The authors concluded that
their study did not reveal an effect of
theophylline on behavior or learning.
In the second study, Schlieper and col-
leagues (Schlieper, Alcock, Beaudry, &
Feldman, 1991) used a double-blind,
randomized crossover design to assess
the effect of theophylline on behavior,
mood, and cognitive processing. They
studied 31 children with 10-day exper-
imental periods separated by 2 drug-
free days. Neither parents' and teach-
ers' ratings nor children's self-ratings
showed theophylline effects. Signifi-
cant variability among subjects was
found regarding individual susceptibil-
ity to theophylline effects. The authors
concluded that children with preexist-
ing attentional or achievement prob-
lems are particularly vulnerable to ad-
verse effects.
In summary, theophylline has been
studied by several groups, with one
group finding a deleterious effect on
behavior and attention and others find-
ing either no differences or improved
performance. Individual susceptibility
to the effects of theophylline (and re-
lated compounds) appears to vary.
This individual variation may help to
explain the diverse findings published
in the literature. Given the inconsis-
tency of the data and the methodolog-
ical limitations of the studies, conclu-
sions about the effects of theophylline
on learning and behavior seem prema-
ture at this time.

The Role of
Psychological Variables
Despite a long tradition of theoreti-
cal and empirical work, the relation-
ship between childhood asthma and
psychological problems remains ob-
scure. Although psychological prob-
lems are no longer viewed as the
primary cause of asthma, emotional
reactions may play a contributory role
in asthmatic episodes (Cohen & Lask,
1983). In addition, asthma symptoms
or their treatment may lead to psycho-
logical problems, particularly among
children with severe, chronic asthma
(McNichol, Williams, Allan, & McAn-
drew, 1973). For example, the neces-
sity to attend and respond to internal
cues (e.g., tightness in one's chest)
may cause anxiety and excessive so-
matic complaints. Somatic complaints
(as measured by the CBC) were found
to be the predominant symptom
among a small sample of children hos-
pitalized for asthma (Furrow, Ham-
bley, & Brazil, 1989).
Psychosocial variables also influence
the successful medical management of
asthma, which in turn contributes to
psychological adjustment. The impor-
tant role of psychosocial variables in
the medical management of asthma is
demonstrated by studies showing that
psychological maladjustment is signifi-
cantly related to theophylline non-
adherence (Christiaanse, Lavigne, &
Lerner, 1989), poorer medical control
of asthma (Norrish, Tooley, & Godfrey,
1977), and death due to asthma (Strunk
et al., 1985). These findings may be in-
terrelated; that is, children with medi-
cation nonadherence have poorly con-
trolled asthma, which places them at
risk for death. However, the patho-
genic mechanism may be more direct.
Miller (1987) speculated that depressed
children with asthma have increased
cholinergic tone, placing them at great-
er risk for an acute attack and sudden
death. As yet, however, there is no
empirical evidence to support such a
pathophysiologic association between
depression and asthma death.
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VOLUME 26, NUMBER 1, JANUARY 1993
Psychological variables appear to
play a mediating role in the develop-
ment of functional impairments, in-
cluding school absenteeism and poor
academic performance. Given the rela-
tionship between psychological mal-
adjustment and medication nonadher-
ence, it is not clear whether poor
academic performance is due primarily
to psychosocial factors or to poor ill-
ness management. Behavior problems
are associated with poor school perfor-
mance among children without chronic
illness (Thompson, Lampron, John-
son, & Eckstein, 1990) as well as
among children with asthma. Taken
together, these findings underscore
the need for a thorough medical and
psychoeducational assessment of chil-
dren with asthma who exhibit delayed
academic achievement.
Implications
and Recommendations
for Educators
The lack of controlled empirical
studies precludes any firm conclusions
about whether children with asthma
are at significantly higher risk for poor
academic performance than children
without asthma. The intermittent na-
ture and variability in severity of
the disease further limit the validity
of generalizations about childhood
asthma. Additional research is needed
to determine the relationships among
frequency and severity of asthma
symptoms, medication adherence,
type of medication, psychological ad-
justment, and academic performance.
Nevertheless, some tentative conclu-
sions can be drawn. Children with fre-
quent exacerbations of asthma leading
to hospitalization are at higher risk for
poor academic performance than com-
parable children without illness.
Several factors may contribute to
poor school performance among chil-
dren with asthma, including iatrogenic
effects of oral steroids, poor medical
management of asthma, and psycho-
logical problems. To enhance the aca-
29
demic performance of children with
asthma, educators and health profes-
sionals are encouraged to (a) imple-
ment self-management programs, (b)
monitor adverse effects of asthma
medication, (c) adopt a multidiscipli-
nary psychoeducational evaluation for
referred children, and (d) institute
educational programs to promote age-
appropriate functioning at home and
school.
Asthma Self-Management
Programs
One intervention that might improve
the school performance of children
with poorly controlled asthma is an
educational self-management pro-
gram. Several asthma self-manage-
ment programs have been developed
to teach children and their parents to
understand the pathophysiology of
asthma and to prevent and manage
symptom exacerbations. The ultimate
goal of these programs is to reduce
morbidity and mortality by enhancing
the efficacy of medical treatment. The
programs vary in instructional format
but typically cover the following topics:
(a) recognizing symptoms of an asthma
attack, (b) administering prescribed
medications correctly and managing
side effects, (c) remaining calm dur-
ing an attack, (d) recognizing and re-
sponding to symptoms that require
emergency care, (e) avoiding or reduc-
ing exposure to known triggers and al-
lergens, (f) normalizing the child's
physical and social activities, and (g)
communicating effectively with health
care personnel.
Self-management programs for
school-age children and their parents
have been shown to improve knowl-
edge about asthma and self-manage-
ment skills, but their overall impact on
reducing morbidity is small (Howland,
Bauchner, & Adair, 1988). Evaluation
of these programs is beset by a num-
ber of methodological problems, in-
cluding inadequate sample sizes, the
lack of reliable and valid outcome mea-
sures, and failure to use tests of statisti-
30
cal significance in evaluating program
success. Nevertheless, the methodo-
logical sophistication of these studies
has improved in recent years. One
study (Clark, Feldman, Evans, Wasi-
lewski, & Levison, 1984) found that
children who attended a health educa-
tion program were significantly more
able to maintain their grade levels than
children who did not attend the pro-
gram. The increased school perfor-
mance appeared to be directly related
to the health education program rather
than to increased attendance or better
adjustment.
Some self-management programs
are designed to be implemented in the
school setting. For example, Parcel and
his colleagues (Parcel, Nader, & Tier-
nan, 1980) developed an education
book that provides a structure for
group teaching for children from kin-
dergarten through the fifth grade.
Parcel et al. found that children in
the program increased significantly in
knowledge about asthma, and those in
the control group did not. The increase
in knowledge was greater for chil-
dren in the upper grades than for
children in the lower grades. Whether
the increased knowledge led to great-
er self-management and, in turn, to in-
creased school attendance and perfor-
mances is unknown.
Monitoring Adverse Effects
of Medication
Individual response to any medica-
tion is the best judge of its proper role
in that person's treatment program.
Children receiving any medication, in-
cluding medication for asthma, should
be observed for adverse effects. When
adverse effects are suspected, careful
evaluation is necessary, possibly in-
cluding a trial of other medication in
place of the suspected offender. When
classroom performance is poorer than
anticipated, psychological assessment
and reassessment of medications being
used is appropriate. This approach re-
quires close working relationships
among physician, teacher, parent, and
patient, who together can strive to
JOURNAL OF LEARNING DISABILITIES
maximize the child's physical and cog-
nitive development.
Multidisciplinary
Psychoeducational Evaluations
Psychological factors appear to play
a crucial role in the medical manage-
ment of asthma. The demands of a
rigorous treatment regimen may prove
too frustrating or anxiety-provoking for
some maladjusted children. For exam-
ple, a hyperactive child may have dif-
ficulty sitting through the 15 minutes
required for a nebulized breathing
treatment. Psychological problems
may also contribute to poor school per-
formance, independent of their asso-
ciation with medical management. In
addition, the use of oral steroids or
theophylline may cause attention and
memory deficits for some children,
which can interfere with their school
performance.
Due to the complex interaction be-
tween medical and psychological vari-
ables in the manifestation and seque-
lae of asthma symptoms, specialized
evaluations that integrate pediatric
(medical) with psychological assess-
ments are needed (see Mrazek & Klin-
nert, 1988, for a review). Children with
asthma who are referred for psycho-
logical assessment due to behavioral or
academic problems are best assessed
by a multidisciplinary team of physi-
cians, educators, and psychologists. In
this way the multiple and related con-
tributions of medical, psychological,
cognitive, and social factors can be
clarified.
Educational Programming
The goal of most health education
programs for children with asthma is
normalization of physical, social, and
educational activities. That is, children
with asthma are encouraged to partic-
ipate in activities as much as their
healthy peers do. Normalization of
psychosocial functioning is thought to
increase the asthmatic child's self-
esteem and confidence, and, in the
Downloaded from ldx.sagepub.com at UNIV TORONTO on November 20, 2014
case of physical conditioning, to im-
prove overall health.
Summary
Although intractable asthma still
exists, most cases of asthma can be
controlled successfully with medica-
tion. For this reason, the illness itself
should not be considered a justification
for evaluation for special education
placement among children with poor
school performance. The available evi-
dence on the relationship of illness fac-
tors and school performance among
children with asthma is insufficient to
warrant this level of intervention. Like
all children, children with asthma
should be evaluated for special educa-
tion placement only after learning dif-
ficulties or behavior problems have
been demonstrated. Before a referral is
made for a formal psychoeducational
evaluation, the child's pediatrician and
parent should be contacted to deter-
mine whether a change in medication
or increased adherence to treatment
might result in improved school per-
formance. If their illness is managed
effectively, children with asthma can
realize their academic potential and
enjoy full, productive lives.
ABOUT THE AUTHORS
Marianne P. Celano, PhD, is a licensed psy-
chologist who specializes in child and adolescent
treatment. She is currently an assistant profes-
sor in the Department of Psychiatry at the
Emory University School of Medicine. She prac-
tices in the Child and Adolescent Psychiatry
Outpatient Clinic of Grady Memorial Hospital
in Atlanta. Robert J. Geller, MD, is a physi-
cian who is board certified in both pediatrics and
medical toxicology. He currently serves as the
medical director of the Georgia Poison Center,
Atlanta, as assistant professor of pediatrics,
Emory University, and as an attending physi-
cian in the Pediatric Allergy Clinic at Grady
Memorial Hospital, Atlanta. Address: Marianne
P. Celano, Department of Psychiatry, Box
26064, Grady Memorial Hospital, 80 Butler St.
SE, Atlanta, GA 30335.

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GLOSSARY
Airway hyperreactivity. A condition in
which the air passages between the out-
side of the body and the actual site of gas
exchange within the lung are oversensi-
tive. Following exposure to relatively
small amounts of irritating materials, the
airways may constrict and impair passage
of air.
Bronchial obstruction. Blockage of the large
airways (leading from the lung segments
to the mouth and nose).
Hypoxemia. Insufficient oxygen concentra-
tion in the blood.
Metered-dose inhaler (MDI). A hand-held
device for delivering a specific dose of an
aerosol spray each time the device is trig-
gered. The canister is typically about
1 inch in diameter and 3 inches tall and
weighs several ounces. The spray is pro-
pelled by a compressed gas within the
canister.
Mucoid secretions. An alteration of a nor-
mal lubricating fluid within the body, in
that the fluid is thicker and more tena-
cious than usual.
Nebulizer. A device for generating an aero-
sol spray of a liquid inserted into the
device. Typical devices are electrically
powered and use air as the propellant gas
for the spray.