Academic Achievement in Children With Asthma
Conditions: Asthma
Sponsor: Shilpa Patel

1 
 
 
 
NCT02228499  
Title: Academic Achievement in Children with Asthma  
Date: June 22, 2018 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

2 
 
 
 
Academic Achievement in Children with Asthma 
Abstract 
Background: Asthma is the most common chronic disease of childhood with a prevalence that is 
1.6 times greater in African American (AA) children than in Non-Hispanic White children.1  
Nationally, 700,000 children are seen for asthma in Emergency Departments (ED) every year, 
1% of which are seen at Children’s National Health System (CN) in Washington, DC. School 
performance and school attendance has not been well studied in urban children with asthma, 
especially at the middle school level. 
Objective: Our purpose is to test the hypothesis that children with asthma have worse school 
performance than middle school children without asthma in Washington DC  public schools.  
Methods: We will conduct a cross-sectional observational study of children in 3rd-8th grade in the 
2015-2016 academic year with and without asthma recruited from the Emergency Departments 
and the IMPACT DC asthma clinic at CN. We will collect demographic information, asthma 
severity information (for cases), and request that parents mail report cards and standardized 
test scores directly to the investigators. We will use multivariable linear and logistic regression to 
determine if the presence of asthma is associated with school performance. 
 
 

3 
 
 
Research Plan 
A. Background and Specific Aims 
Asthma is the most common chronic disease of childhood with a prevalence that is 1.6 
times greater in African American (AA) children than in Non-Hispanic White children.1  
Nationally, 700,000 children are seen for asthma in Emergency Departments (ED) every year, 
1% of which are seen at Children’s National Medical Center (CN) in Washington, DC. The 
asthma prevalence rate among African America (AA) children and teens in Washington, DC is 
20% higher than the national rate2 and overall ED utilization rates for asthma are 4.3 times the 
national rate.3 In 2007, approximately 10.5 million school days were lost due to asthma.1    
 
Asthma severity may impact academic performance due to increased absenteeism. A 
study of Canadian school children showed that children with the most severe asthma had the 
lowest math and reading scores.4 Tsakiris also showed that children with asthma on inhaled 
corticosteroids had better academic achievement than children with asthma not on long-term 
controller therapy, suggesting that poor control is associated with worse school performance.5 
However, academic performance is dependent on many other factors, such as socio-
economic status of the local district and resources available. Availability of skilled nursing differs 
between schools, impacting children with asthma; Hillemeier’s study of children with asthma in 
Pennsylvania schools showed that less than half of secondary schools had adequate school 
nurse coverage, and that this reduced services provided to children with asthma.6 Children 
whose asthma is not managed at school may be absent more often. Parental education also 
plays a part in a child’s school performance. Tsakiris et al, showed that in Greece, lower 
parental education level was independently associated with poor school performance in children 
with asthma.5  
Early adolescence (ages 10-13) is identified as a time of great transition with both 
developmental and biologic changes; in this time period male children with asthma generally 
improve and female with asthma develop worsening asthma, likely due to hormone effects. It 
has been shown that programs to reduce asthma symptoms in both younger children 
(elementary school) and older children (high school) do not work well in early adolescent 
children (middle school).7   
In addition, despite the National Asthma Education Prevention Program (NAEPP, 2007) 
guidelines that encourage the assessment of the quality of life (QOL) in children, there has been 
minimal research on QOL in children with asthma.  
Given the scarcity of information on the association between pediatric asthma and 
academic achievement, school attendance, and the QOL, and the need to establish baselines 
within individual communities, we have designed a study to examine the association between 
asthma in children in grades 3-8 and academic achievement, school attendance, and the QOL.  
Our overall hypothesis is that children with asthma will have worse school performance 
compared to children without asthma.    
Specific Aim 1: To determine the association between asthma and school performance by 
comparing grade point averages (GPA) in children from 3rd-8th grade with and without asthma. 
We will enroll an additional 60  children in grades 3-8 with asthma (cases) from the ED/IMPACT 
DC and compare them with a group of 60 children in grades 3-8 without asthma (controls) 
recruited from the ED.  Report cards will be collected between May 2016-November 2016or until 
60 cases and 60 controls have been recruited, and GPAs will be compared. We expect children 
with asthma will have lower GPAs . 

4 
 
B.  
Significance:  
School achievement in elementary and middle school students with asthma is not well 
understood; this study will be pivotal in identifying if middle school students with asthma in the 
Washington DC are performing more poorly than their non-asthmatic counterparts.  
 
C. Preliminary studies 
We have not previously studied academic success in children with asthma. 
 
D. Research Design and Methods 
 
We are proposing a cross-sectional case-control observational study of children in grades 3-8 to 
compare academic achievement and school attendance between children with and without 
asthma. 60 children with asthma (cases) will be recruited from the IMPACT DC clinic and/or ED 
and 60 children without asthma (controls) will be recruited from the ED. Recruitment will occur 
from May 2016 through November 2016.  
 
Inclusion criteria for cases include asthma diagnosed by a clinician for greater than 1 
year with a history of exacerbation requiring systemic corticosteroids within the past 2 years. 
Controls will have no history of asthma. All children, cases and controls, must (1) be in grade 
level 3-8 in the 2015-2016 school year, attend public school in Washington, DC (DCPS) and 
reside in their school district;(2) be accompanied by their parent or legal guardian. Exclusion 
criteria for cases and controls will be (1) presence of a chronic medical condition other than 
asthma or (2) a family that does not speak English or Spanish. 
 
Demographic Data for Cases and Controls 
Demographic information will be obtained by a structured interview; the questionnaire (Appendix 
A) will be used on both cases and controls: the parent/caregiver will be asked about the child’s 
age, gender, race/ethnicity, insurance type. health care utilization, medications usage,  highest 
level of education of the parent/ caregiver, income of the household, and parental report of 
school services.  Cases will complete an additional 11 questions to determine asthma severity 
to determine NAEPP score and the Asthma Control Test (ACT) score (Appendix F and G).   
 
We will utilize the child’s electronic medical record (Cerner for ED charts and eClinicalWorks for 
the IMPACT DC charts) to determine insurance type and health care utilization. We will also 
determine each participant’s weight and height from the medical record and will access medical 
records for the period of time we are collecting report cards for to determine clinical information, 
such as number of ED visits and hospitalizations over the 14 month period that the report cards 
cover (August 2015-November 2016).  
 
Reporting of Academic Achievement and School Attendance 
At the time of recruitment, families will be given a self-addressed, stamped envelope to send the 
child’s 2013 first term (if available), standardized test score report (if available), and final report 
card to the research team. All report cards/score reports will be returned to the family via US 
Mail. Academic achievement, standardized test scores, and school attendance will be recorded 
from the report cards.  All report cards in the DCPS system use the same grading scale.. 
 
The Self-Perception Profile 
The self-perception profile is a reliable validated 6 question questionnaire for children in grades 
6-8 that allows a child to self-evaluate their feelings about their engagement in school and their 
own school performance.  

5 
 
 
Reporting of the Quality of Life using the Peds QL 4.0 Form 
QOL will be measured using the validated PedsQL 4.0 for children, teens, and parents 
(Appendices B, C, D, and E).   The PedsQL 4.0 has four scales with 23 questions which 
ascertain physical functioning, emotional functioning, social functioning, and school functioning.   
A 5-point Likert scale is used in the child self-report and for the parent proxy reports. Items are 
reverse scored and linearly transformed to a 0 to 100 scale (0=100, 1=75, 2=50, 3=25, and 
4=0), so higher scores indicate better QOL.  
 
E. Statistical analysis Descriptive statistics will be used to analyze demographic variables 
(rates, proportions, means, medians, ranges). Univariate comparisons will be performed 
using appropriate categorical or continuous statistical analyses. Multivariate testing will 
be performed using logistic and/or liner regression where appropriate. 
 
Sample Size: The study will be powered on the proportion of patients in each group with 
a grade point average >3.0. The overall proportion of DC public middle school students 
in the 2012-2013 school year with a GPA >3.0 was approximately 35%. Assuming that 
this figure is similar for children without asthma (controls), we will need 70 cases and 70 
controls to have 80% power detect a 20% absolute difference in the proportion of 
children with asthma (cases) with a grade point average >3.0 (alpha = 0.05, two-sided). 
 
We have chosen to include 120 children in the expansion of this original study, as we 
expect that less than 50% of all included patients will return their final year report cards 
via the self-addressed, stamped envelope. 
 
F. Human Subjects 
A convenience sample of potential participants’ guardians will be approached in the 
temporal sequence that they are available either in the emergency department or in the 
IMPACT DC Asthma Clinic, informed about the research study, and invited to participate.  
Informed consent will obtained from all guardians. 
 
After obtaining informed consent, trained research assistants and/or the investigators will 
use extant hospital electronic data and information obtained from questionnaires as the 
source of research material for this study. 
 
1. The risks of this study include inadvertent disclosure of protected health 
information. This risk does not exceed the daily risk of inadvertent disclosure of 
patients’ protected health information during ED operations where patients’ 
records are accessed through the ED tracking system of Logicare and the 
electronic medical records of EPRS. 
2. There is the risk of feeling uncomfortable during the questionnaires; families will 
be told that some of the questions may make them uncomfortable and they are 
welcome to leave the study at any time, without penalty, if they feel 
uncomfortable. Alternatively, they may choose to leave questions unanswered. 
3. There are no direct benefits to study participants. However, the knowledge 
gained from this study may allow us to identify a cohort of patients at special 
risk, for whom a targeted intervention would be appropriate. 

6 
 
4. Therefore, the risks are reasonable in relation to the benefits. 
 
G. Risks and Side Effects 
Questionnaires  
Participants may find some of the questionnaires too personal; they will be offered the 
opportunity to refuse to answer any questions that make them feel uncomfortable.   
There is also the risk of breach of confidentiality; all participants will be assigned a 
random study number. This study number will be used to identify all questionnaires. 
Coding for the study numbers will be secured on a password protected file on the PI’s 
hospital-issued laptop and stored on the secure CNMC server.  We will store the study 
data in locked cabinets or offices.  
 
H. Benefits 
 
There are no direct benefits to participants. 
 
I. Outside Consultants/Collaborators  
 
 
 
None. 
 
 
J. 
Contractual Agreements   
   
 
 
None.  
 
K. 
Costs To Subjects: 
 
 
There is no cost to subjects.   
 
L. 
Conflicts Of Interest: 
 
There are no conflicts of interest.  
 
M. 
Confidentiality: 
The investigators will use reasonable measures to assure the security of these data, 
including locked office doors and file cabinets where paper records are stored, and secure, 
password-protected, computer software systems where electronic data are stored. The 
major risks to patients are the risks to confidentiality by inadvertent disclosure of protected 
health information. All paper data will be kept in the PI’s locked office in locked file cabinets, 
to which only the PI will have keys for. All protected health information will be secured in 
password protected databases on the hospital Emergency Medical and Trauma Center 
(EMTC) drive. All research data will be de-identified and coded to further protect patient 
confidentiality. Code numbers and they respective medical record numbers will be kept in a 
separate password-protected database on the hospital’s EMTC server. Passwords will only 
be known to the PI. These risks are reasonable in relation to the future anticipated benefits, 
which include identifying a future cohort of patients who might benefit from targeted 
interventions. The risk of inadvertent disclosure of protected health information is no more 
than minimal and no more than encountered on any patient visit to the ED.  
 
 
 

7 
 
N. 
Subject Compensation:  
 There will be no compensation for subjects on the expanded continuing portion of this study. 
O. 
Facilities and Equipment 
 
Existing departmental facilities will be used.  
 
 
P. 
References & Literature Cited  
 
1. 
Akinbami LJ, Moorman JE, Garbe PL, Sondik EJ. Status of childhood asthma in the United States, 
1980-2007. Pediatrics. Mar 2009;123 Suppl 3:S131-145. 
2. 
Moorman JE, Rudd RA, Johnson CA, et al. National surveillance for asthma--United States, 1980-
2004. MMWR Surveill Summ. Oct 19 2007;56(8):1-54. 
3. 
Teach SJ. www.impact-dc.org. 2010. 
4. 
Kohen DE. Asthma and school functioning. Health reports. Dec 2010;21(4):35-45. 
5. 
Tsakiris A, Iordanidou M, Paraskakis E, et al. The presence of asthma, the use of inhaled steroids, 
and parental education level affect school performance in children. BioMed research 
international. 2013;2013:762805. 
6. 
Hillemeier MM, Gusic ME, Bai Y. Rural and urban children with asthma: are school health 
services meeting their needs? Pediatrics. Sep 2006;118(3):1097-1103. 
7. 
Clark NM, Dodge JA, Thomas LJ, Andridge RR, Awad D, Paton JY. Asthma in 10- to 13-year-olds: 
challenges at a time of transition. Clin Pediatr (Phila). Oct 2010;49(10):931-937. 
 
 
 
 
 
 

8 
 
 
 
Appendix A 
 
 
 
 
 
Case#
__________ 
 Understanding the Impact of Asthma in Academic Achievement, School Attendance, and 
in the Quality of Life in Middle school aged children Questionnaire 
Baseline Measure 
These questions will ask about your child’s background and asthma history.  In order for this 
study to be useful for families of children with asthma, it is important that everyone give us 
accurate answers.  IMPACT DC team members will not share or discuss any personal 
information without your permission.   
 
If you have any questions, please let me know.  If not, we can start. 
 
  
**Note to Interviewers: 
- 
Bold scripting is meant to be read to participants.   
- 
[Italicized in brackets] scripting is a note for clarification that is not meant to be read 
aloud. 
 

9 
 
General Information 
Interviewer’s Initials    
 
 
____ ____ ____ 
Interview Date  
 
 
 
___ ___/___ ___/___ ___ (mm/dd/yy) 
Time of Interview Start 
 
 
___ ___ : ___ ___ [based on 24-hr clock] 
Patient’s Initials 
 
 
 
____ ____ ____ 
Patient’s Date of Birth  
 
 
__ __/__ __/__ __ __ __ (mm/dd/yyyy) 
Patient’s Gender 
 
 
 
 Male  
 Female 
Which grade did your child complete in the last 12 months at school_____________ 
Two best contact phone numbers_________________ and____________________ 
Best contact Address__________________________________________________ 
___________________________________________________________________ 
Health Care Utilization 
Let me ask you about your visits to any hospitals other than Children’s National on 
Michigan Avenue and the Children’s National Emergency Room at the United Medical 
Center: 
In the last 12 months, have you been to an Emergency Room other than the Children’s 
Emergency Room at either Children’s National or the United Medical Center? 
1. ⁯No [Skip to next section] 
⁯Yes [go to question 5] 
 
2. How many times in the last 12 months has (CHILD) been to an Emergency 
Room other than the Children’s Emergency Room at either Children’s National or 
the United Medical Center? 
 
 
 
_______ times 
3. How many times in the last 12 months has (CHILD) been admitted to a hospital 
other than Children’s National Medical Center for asthma? 
 
 
_______ times 

10 
 
4. How many times in the last 12 months has (CHILD) been in the PICU (Pediatric 
Intensive Care Unit) of a hospital other than Children’s National Medical Center? 
 
 
 
_______ times 
Current Medication Use 
[Do not read options for types of medicines.  Just read question as worded, and then record 
actual response and classify medication.  Do not show pictures or demos/samples of asthma 
medicines.  If name unknown but respondent describes medication, or medication is unknown, 
write down actual response and classify as “Other”.] 
5. During the past two days, did [CHILD] take or use any medications including pills, 
syrups, or inhaled medications?  
 
⁯Yes 
 ⁯No [skip to question 6) ⁯Don’t know [skip to question 7) 
 
 
If yes: 
 Which medicines? _______________________ 
 
Asthma Medications: 
 
Inhaled or nebulized steroid (ex. Pulmicort, Flovent, QVAR, Asmanex) 
 
Short-acting bronchodilator (ex. albuterol, Ventolin, ProAir, Xopenex) 
 
Long-acting bronchodilator (ex. salmeterol, formoterol) 
 
Inhaled steroid/LABA combination (ex. Advair, Symbicort, Dulera) 
 
Long-acting leukotriene inhibitor (ex. Singulair)  
 
Oral Steroid (Prednisone, Prednisolone, Dexamethasone)  
 
Other: ___________________       
 
 
Allergy Medications: 
  Antihistamines 
 Intranasal Steroid 
 Other: ___________________ 
Non-asthma/allergy medication: 
 ___________________ 

11 
 
Adherence: 
6. Does your child take a daily medicine? 
Yes  
   No [Skip to question 7]  
 
 What is the name of this medication: _________________ 
Asthma Medications: 
 
 Inhaled or nebulized steroid (ex. Pulmicort, Flovent, QVAR, Asmanex) 
 
Short-acting bronchodilator (ex. albuterol, Ventolin, ProAir, Xopenex) 
 
Long-acting bronchodilator (ex. salmeterol, formoterol) 
 
Inhaled steroid/LABA combination (ex. Advair, Symbicort, Dulera) 
 
Long-acting leukotriene inhibitor (ex. Singulair)  
 
Oral Steroid (Prednisone, Prednisolone, Dexamethasone)  
 
Other: ___________________       
 
 
Allergy Medications: 
  Antihistamines 
 Intranasal Steroid 
Other: _________________ 
 
Non-asthma/allergy medication: ________________ 
Demographic / Family History  
Finally, research studies always ask a few questions about your family background. 
7. What do you consider [CHILD]’s race to be? [Read options and circle all that 
apply] 
⁯Black or African-American  
⁯ White 
 
 
 
 
⁯Asian  
 
 
 
⁯American Indian or Alaska Native   
⁯Native Hawaiian/Pacific Islander  ⁯Some other race: _____________________ 
1. What do you consider [CHILD]’s ethnicity to be? [Read options] 
⁯Hispanic 

12 
 
⁯Non-Hispanic 
⁯Other: _____________________ 
8. Do any of [CHILD]’s parents, brothers, or sisters have asthma? [Include those 
who do and do not live in household.] 
⁯Yes  
 
⁯No  
⁯Don’t know 
9. How many days of school did you child miss over the last school year due to 
asthma? 
 
10. Does your child receive any special services at school? What are they? 
 
 
 
 
11. What is the highest grade or school level that you have completed? 
⁯Never attended school 
 ⁯Grade 1-11 
 ⁯GED or 12th grade 
 ⁯Some college/technical/vocational training 
 ⁯College graduate 
   ⁯Other: _________________ 
12. Keeping in mind the various possible sources of income for your household, such 
as a job, supplemental security income (SSI) or disability, social security, public 
assistance, food stamps, unemployment compensation, and child support, what 
was the total income during [LAST CALENDAR YEAR] from all sources for 
everyone in your household?  Please point to the answer closest to your total 
household income. 
 
[Show categories listed on hand card.  Ask for last full calendar year.  If the respondent 
cannot give a figure, go over each source of income and get an estimate per month and 
multiply by twelve] 

13 
 
⁯$5,000 or less 
 
⁯$5,001   - $10,000  
⁯$10,001 - $20,000 
⁯$20,001 - $30,000  
⁯ $30,001 - $40,000 
⁯$40,001 - $50,000 
⁯$50,001 - $60,000  
⁯$60,001 - $70,000  
⁯$70,001 - $80,000 
 
⁯$80,001 - $90,000  
⁯$90,001 - $100,000 
⁯$100,001 - $150,000
 
⁯$150,001 - $200,000  
⁯$200,001 - $250,000 
⁯$250,001 or greater 
 
⁯Refused   
 
⁯Don’t know 
Thank you very much for answering all of my questions.  Your answers will help us 
improve care for children with asthma.  As we discussed earlier, you will be 
compensated with a $25 gift card after mailing us your child’s report card. 
 ⁯ [Caregiver given copy of informed consent document] 
Time of Interview End  
 
___ ___ : ___ ___  [based on 24-hr clock] 
Interviewer Comments 
Please indicate if respondent had difficulty answering any of the questions, you feel they 
provided inaccurate or misleading responses, there were any unusual circumstances at the time 
of the interview, or the respondent had a language or literacy problem.  Please reference 
specific questions if appropriate. 
__________________________________________________________________ 
 
            
__________________________________________________________________ 
 
__________________________________________________________________ 
 
__________________________________________________________________ 
Chart Review 
[To be completed after visit in IMPACT DC Asthma Clinic is completed] 
From IMPACT DC Clinic Form: 

14 
 
13. Final Asthma Classification [based on clinician’s assessment]  
⁯Intermittent 
⁯Mild Persistent 
⁯Moderate Persistent 
⁯Severe Persistent  
14. Insurance type 
 
12a. Name of child’s insurance provider: ____________________________ 
12b. Insurance type: 
 
⁯Public 
 
⁯Private 
 
⁯None 
 
⁯Unknown 
15. Zip code of residence: _________  
 
16. Oral Steroids: How many courses of oral steroids in the prior 12 months:   
 
 
 
 
___________ 
17. If applicable: If a patient is already using an ICS, what was the number of puffs 
displayed on the back of the inhaler they are currently using?  
_____________ of puffs 
From Medical Records: 
Health Care Utilization [from medical records, visits to Children’s Hospital or any of the 
Goldberg Center Children’s Health Centers]: 
Emergency Department visits for asthma  
  
18. Number of ED visits in prior 12 months: __________ 
19. Hospitalizations for asthma__________________ 
20. Number of hospitalizations in prior 12 months: __________ 
21. PICU Admissions 

15 
 
 
Number of PICU admissions in the last 12 months: ___________  
      21.Urgent care visits for asthma (if Goldberg Center patient) 
 
 
 
Number of urgent care visits in prior 12 months: __________ 
Appendix B 
PedsQL ™  
Pediatric Quality of Life  
Inventory  
Version 4.0 
PARENT REPORT for CHILDREN (ages 8-12) 
 
DIRECTIONS 
     On the following page is a list of things that might be a problem for your child. 
     Please tell us how much of a problem each one has been for your child 
     during the past  ONE  month by circling: 
0 if it is never a problem  
1 if it is almost never a problem  
2 if it is sometimes a problem 
3 if it is often a problem 
4 if it is almost always a problem 
 
     There are no right or wrong answers.   
     If you do not understand a question, please ask for help. 
 
 
 

16 
 
In the past ONE month, how much of a problem has your child had with  
PHYSICAL FUNCTIONING (problems with…) 
Never 
Almos
t 
Never 
Some-
times 
Often 
Almost 
Always 
1.  Walking more than one block 
0 
1 
2 
3 
4 
2.  Running 
0 
1 
2 
3 
4 
3.  Participating in sports activity or exercise  
0 
1 
2 
3 
4 
4.  Lifting something heavy 
0 
1 
2 
3 
4 
5.  Taking a bath or shower by him or herself  
0 
1 
2 
3 
4 
6.  Doing chores around the house  
0 
1 
2 
3 
4 
7.  Having hurts or aches 
0 
1 
2 
3 
4 
8.  Low energy level 
0 
1 
2 
3 
4 
 
EMOTIONAL FUNCTIONING (problems with…) 
Never 
Almost 
Never 
Some-
times 
Often 
Almost 
Always 
1.  Feeling afraid or scared 
0 
1 
2 
3 
4 
2.  Feeling sad or blue 
0 
1 
2 
3 
4 
3.  Feeling angry 
0 
1 
2 
3 
4 
4.  Trouble sleeping 
0 
1 
2 
3 
4 
5.  Worrying about what will happen to him or her 
0 
1 
2 
3 
4 
SOCIAL FUNCTIONING (problems with…) 
Never 
Almost 
Never 
Some-
times 
Often 
Almost 
Always 
1.  Getting along with other children 
0 
1 
2 
3 
4 
2.  Other kids not wanting to be his or her friend 
0 
1 
2 
3 
4 
3.  Getting teased by other children 
0 
1 
2 
3 
4 
4.  Not able to do things that other children his or her 
age can do
0 
1 
2 
3 
4 
5.  Keeping up when playing with other children 
0 
1 
2 
3 
4 
SCHOOL FUNCTIONING (problems with…) 
Never 
Almost 
Never 
Some-
times 
Often 
Almost 
Always 
1.  Paying attention in class 
0 
1 
2 
3 
4 
2.  Forgetting things 
0 
1 
2 
3 
4 
3.  Keeping up with schoolwork 
0 
1 
2 
3 
4 

17 
 
4.  Missing school because of not feeling well  
0 
1 
2 
3 
4 
5.  Missing school to go to the doctor or hospital 
0 
1 
2 
3 
4 
Appendix C 
PedsQL ™  
Pediatric Quality of Life  
Inventory 
 
Version 4.0 
CHILD  REPORT (ages 8-12) 
 
DIRECTIONS 
 
     On the following page is a list of things that might be a problem for you. 
     Please tell us how much of a problem each one has been for you 
     during the past  ONE  month by circling: 
0 if it is never a problem  
1 if it is almost never a problem  
2 if it is sometimes a problem 
3 if it is often a problem 
4 if it is almost always a problem 
 
     There are no right or wrong answers.   
     If you do not understand a question, please ask for help. 
 
In the past ONE month, how much of a problem has this been for you …     

18 
 
ABOUT MY HEALTH AND ACTIVITIES (problems with…) 
Never 
Almost 
Never 
Some-
times 
Often 
Almos
Alway
1.  It is hard for me to walk more than one block 
0 
1 
2 
3 
4 
2.  It is hard for me to run 
0 
1 
2 
3 
4 
3.  It is hard for me to do sports activity or exercise 
0 
1 
2 
3 
4 
4.  It is hard for me to lift something heavy 
0 
1 
2 
3 
4 
5.  It is hard for me to take a bath or shower by myself  
0 
1 
2 
3 
4 
6.  It is hard for me to do chores around the house  
0 
1 
2 
3 
4 
7.  I hurt or ache  
0 
1 
2 
3 
4 
8.  I have low energy 
0 
1 
2 
3 
4 
   
ABOUT MY FEELINGS (problems with…) 
Never 
Almost 
Never 
Some-
times 
Often 
Almos
Alway
1.   I feel afraid or scared 
0 
1 
2 
3 
4 
2.   I feel sad or blue 
0 
1 
2 
3 
4 
3.   I feel angry 
0 
1 
2 
3 
4 
4.   I have trouble sleeping 
0 
1 
2 
3 
4 
5.   I worry about what will happen to me 
0 
1 
2 
3 
4 
 
HOW I GET ALONG WITH OTHERS (problems with…) 
Never 
Almost 
Never 
Some-
times 
Often 
Almos
Alway
1.  I have trouble getting along with other kids 
0 
1 
2 
3 
4 
2.  Other kids do not want to be my friend  
0 
1 
2 
3 
4 
3.  Other kids tease me  
0 
1 
2 
3 
4 
4.  I cannot do things that other kids my age can do 
0 
1 
2 
3 
4 
5.  It is hard to keep up when I play with other kids 
0 
1 
2 
3 
4 
 ABOUT SCHOOL (problems with…) 
Never 
Almost 
Never 
Some-
times 
Often 
Almos
Alway
1.   It is hard to pay attention in class 
0 
1 
2 
3 
4 
2.   I forget things 
0 
1 
2 
3 
4 
3.   I have trouble keeping up with my schoolwork 
0 
1 
2 
3 
4 
4.   I miss school because of not feeling well  
0 
1 
2 
3 
4 
5.   I miss school to go to the doctor or hospital 
0 
1 
2 
3 
4 
 

19 
 
Appendix D 
PedsQL ™  
Pediatric Quality of Life  
Inventory  
 
Version 4.0 
PARENT REPORT for TEENS (ages 13-18) 
 
 
DIRECTIONS 
 
     On the following page is a list of things that might be a problem for your teen. 
     Please tell us how much of a problem each one has been for your teen 
     during the past  ONE  month by circling: 
0 if it is never a problem  
1 if it is almost never a problem  
2 if it is sometimes a problem 
3 if it is often a problem 
4 if it is almost always a problem 
     There are no right or wrong answers.   
     If you do not understand a question, please ask for help. 
 
 
In the past ONE month, how much of a problem has your teen had with … 

20 
 
PHYSICAL FUNCTIONING (PROBLEMS WITH…) 
Never 
Almost 
Never 
Some-
times 
Often 
Almost 
Always 
1.  Walking more than one block 
0 
1 
2 
3 
4 
2.  Running 
0 
1 
2 
3 
4 
3.  Participating in sports activity or exercise  
0 
1 
2 
3 
4 
4.  Lifting something heavy 
0 
1 
2 
3 
4 
5.  Taking a bath or shower by him or herself  
0 
1 
2 
3 
4 
6.  Doing chores around the house  
0 
1 
2 
3 
4 
7.  Having hurts or aches 
0 
1 
2 
3 
4 
8.  Low energy level 
0 
1 
2 
3 
4 
 
EMOTIONAL FUNCTIONING (PROBLEMS WITH…) 
Never 
Almost 
Never 
Some-
times 
Often 
Almost 
Always 
1.  Feeling afraid or scared 
0 
1 
2 
3 
4 
2.  Feeling sad or blue 
0 
1 
2 
3 
4 
3.  Feeling angry 
0 
1 
2 
3 
4 
4.  Trouble sleeping 
0 
1 
2 
3 
4 
5.  Worrying about what will happen to him or her 
0 
1 
2 
3 
4 
SOCIAL FUNCTIONING (PROBLEMS WITH…) 
Never 
Almost 
Never 
Some-
times 
Often 
Almost 
Always 
1.  Getting along with other teens 
0 
1 
2 
3 
4 
2.  Other teens not wanting to be his or her friend 
0 
1 
2 
3 
4 
3.  Getting teased by other teens 
0 
1 
2 
3 
4 
4.  Not able to do things that other teens his or her age can 
do  
0 
1 
2 
3 
4 
5.  Keeping up with other teens 
0 
1 
2 
3 
4 
SCHOOL FUNCTIONING (PROBLEMS WITH…) 
Never 
Almost 
Never 
Some-
times 
Often 
Almost 
Always 
1.  Paying attention in class 
0 
1 
2 
3 
4 
2.  Forgetting things 
0 
1 
2 
3 
4 
3.  Keeping up with schoolwork 
0 
1 
2 
3 
4 
4.  Missing school because of not feeling well  
0 
1 
2 
3 
4 
5.  Missing school to go to the doctor or hospital 
0 
1 
2 
3 
4 
 

21 
 
Appendix E 
PedsQL ™  
Pediatric Quality of Life  
Inventory 
 
Version 4.0 
TEEN REPORT (ages 13-18) 
 
 
DIRECTIONS 
 
     On the following page is a list of things that might be a problem for you. 
     Please tell us how much of a problem each one has been for you 
     during the past  ONE  month by circling: 
 
0 if it is never a problem  
1 if it is almost never a problem  
2 if it is sometimes a problem 
3 if it is often a problem 
4 if it is almost always a problem 
 
     There are no right or wrong answers.   
     If you do not understand a question, please ask for help. 
 
 
In the past ONE month, how much of a problem has this been for you … 

22 
 
ABOUT MY HEALTH AND ACTIVITIES (problems with…) 
Never  Almost 
Never 
Some-
times 
Often 
Almost 
Always 
1.  It is hard for me to walk more than one block 
0 
1 
2 
3 
4 
2.  It is hard for me to run 
0 
1 
2 
3 
4 
3.  It is hard for me to do sports activity or exercise  
0 
1 
2 
3 
4 
4.  It is hard for me to lift something heavy 
0 
1 
2 
3 
4 
5.  It is hard for me to take a bath or shower by myself  
0 
1 
2 
3 
4 
6.  It is hard for me to do chores around the house  
0 
1 
2 
3 
4 
7.  I hurt or ache  
0 
1 
2 
3 
4 
8.  I have low energy 
0 
1 
2 
3 
4 
 
ABOUT MY FEELINGS (problems with…) 
Never  Almost 
Never 
Some-
times 
Often 
Almost 
Always 
1.   I feel afraid or scared 
0 
1 
2 
3 
4 
2.   I feel sad or blue 
0 
1 
2 
3 
4 
3.   I feel angry 
0 
1 
2 
3 
4 
4.   I have trouble sleeping 
0 
1 
2 
3 
4 
5.   I worry about what will happen to me 
0 
1 
2 
3 
4 
HOW I GET ALONG WITH OTHERS (problems with…) 
Never 
Almost 
Never 
Some-
times 
Often 
Almost 
Always 
1.  I have trouble getting along with other teens 
0 
1 
2 
3 
4 
2.  Other teens do not want to be my friend  
0 
1 
2 
3 
4 
3.  Other teens tease me  
0 
1 
2 
3 
4 
4.  I cannot do things that other teens my age can do 
0 
1 
2 
3 
4 
5.  It is hard to keep up with my peers 
0 
1 
2 
3 
4 
   ABOUT SCHOOL (problems with…) 
Never 
Almost 
Never 
Some-
times 
Often 
Almost 
Always 
1.   It is hard to pay attention in class 
0 
1 
2 
3 
4 
2.   I forget things 
0 
1 
2 
3 
4 
3.   I have trouble keeping up with my schoolwork 
0 
1 
2 
3 
4 
4.   I miss school because of not feeling well  
0 
1 
2 
3 
4 
5.   I miss school to go to the doctor or hospital 
0 
1 
2 
3 
4 
 

23 
 
Appendix F 
 
 
 
 
Case#_____________________ 
Understanding the Impact of Asthma in Academic Achievement, School Attendance, and 
in the Quality of Life in Middle school aged children Questionnaire Using The NAEPP, 
2007 guidelines 
 
The next series of questions will ask about your child’s severity of asthma, it is important that everyone give us 
accurate answers. The team members will not share or discuss any personal information without your permission. 
Only the other team members will be able to see your answers to questions or your name. Everything is kept private 
and strictly confidential. None of your answers will in any way affect your medical care, benefits, any services you 
may be receiving (such as Medicaid or WIC) or your job or immigration status. You can decide at any point not to 
participate in the study, and your decision won’t have any impact on your current or future medical care.  
If you have any questions, please let me know. If not, we can start. 
The next series of questions will ask about child’s asthma over the past 2-4 weeks. Please listen 
to all the possible responses and then pick the one that best describes the child situation.  You 
must pick the single best answer that describes the childs situation over the prior 2-4 weeks.  
So think about the last 2-4 weeks…. 
1…how often during the day did _____________have asthma symptoms? 
5-11 years 
 
Severity 
 
Control 
a 
<2d/wk 
a 
< 2d/wk but not > 
1x/d 
b 
>2d/wk but not 
daily 
b 
>2d/wk or many 
times on< 2d/wk 
c 
Daily 
d 
Throughout the 
day 
c 
Throughout the 
day 
 
>  12 years 
 
Severity 
 
Control 
a 
<2d/wk 
a 
< 2d/wk but not > 
1x/d 
b 
>2d/wk but not 
daily 
b 
>2d/wk or many 
times on< 2d/wk 
c 
Daily 
d 
Throughout the 
day 
c 
Throughout the 
day 
2…how often during the night did _____________awake due to asthma symptoms? 

24 
 
 
 
> 12 years 
 
Severity 
 
Control 
a 
<2x/month 
a 
< 2x/month 
b 
3-4 x/month 
b 
1-3x/wk 
c 
>1x/wk but not 
nightly 
c 
>4x/wk 
d 
Often 7x/wk 
 
 
 
3…how often during the night did _____________use albuterol, quick relief medicines, 
for asthma symptoms?  (please do not include albuterol before exercise or heavy play to 
avoid wheezing due to exercise). 
5-11 years 
 
Severity 
 
Control 
a 
<2d/wk 
a 
< 2d/wk 
b 
>2d/wk but not 
daily 
b 
>2d/wk 
c 
Daily 
d 
several x/d 
c 
several x/d 
 
>  12 years 
 
Severity 
 
Control 
a 
<2d/wk 
a 
< 2d/wk  
b 
>2d/wk but not 
daily 
b 
>2d/wk  
c 
Daily 
d 
Several x/d 
c 
Throughout the 
day 
 
4…how often did asthma interfere with the childs normal activity. 
5-11 years 
 
Severity 
 
Control 
a 
None 
a 
none 
b 
minor limitation 
b 
some limitation 
5-11 years 
 
Severity 
 
Control 
a 
<2x/month 
a 
0-1x/month 
b 
3-4 x/month 
b 
>2x/month 
c 
>1x/wk but not 
nightly 
c 
>2x/wk 
d 
Often 7x/wk 
 
 

25 
 
c 
some limitation 
d 
extremely limited 
c 
extremely limited 
 
>  12 years 
 
Severity 
 
Control 
a 
None 
a 
none 
b 
minor limitation 
b 
some limitation 
c 
some limitation 
d 
extremely limited 
c 
extremely limited 
 
5…Now I need to know how many separate times child took steroids by mouth over the 
last year to treat an asthma attack.  A steroid by mouth is a pill or syrup that is taken for 
a short period of time to treat asthma attacks. 
5-11 years 
 
Severity 
 
Control 
a 
0-1/last year 
a 
0-1/last year 
b 
>2x last year 
b 
>2xlast year 
 
>12 years 
 
Severity 
 
Control 
a 
0-1/last year 
a 
0-1/last year 
b 
>2x last year 
b 
>2xlast year 
 
 
 
 
 
 
 
 
 
 
 
 

26 
 
Appendix G 
  
 
 Case#_____________________ 
Understanding the Impact of Asthma in Academic Achievement, School Attendance, and 
in the Quality of Life in Middle school aged children 
The American Lung Association recommends everyone 12 years of age and older with asthma take the Asthma 
ControlTest, no matter how well controlled you think your asthma is.  Your answers to this 5-question quiz will 
provide you a score that may help you and your doctor determine if your treatment plan is working or if it might 
be time for a change. 
How to take the Asthma Control Test 
Step 1. Write the number of each answer in the score box provided. 
Step 2. Add up each score box for your total. 
Step 3. Take the test to your doctor to talk about your total score.  
1.In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school 
or at home? 
all the time 
1 
most of the time 
2 
some of the time 
3 
a little of the time 
4 
None of the time 
5 
 
 
2.During the past 4 weeks, how often have you had shortness of breath? 
More than 
once a day 
1 
Once a day 
 
2 
3-5 times a week 
 
3 
Once or twice a 
week 
4 
 Not at all 
 
5 
 
 
3.During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest 
tightness or pain) wake you up at night or earlier than usual inthe morning?  
 
4 or more 
nights a week 
1 
2-3 nights a 
week 
2 
once a week 
 
3 
once or twice 
 
4 
Not at all 
 
5 
 
 
4.During the past 4 weeks,how often have you used your rescue inhaler  or nebulizer medication (such as 
albuterol)? 
3 or more times 
per day 
1 
1-2 times 
per day 
2 
2-3 times per week 
3 
once a week or less 
4 
 Not at all 
 
5 
 
 
5.How would you rate your asthma control during thepast 4 weeks? 
not controlled at 
all 
1 
poorly 
controlled 
2 
somewhat 
controlled 
3 
well controlled 
 
4 
completely 
controlled 
5 
 
 
 

27 
 
Appendix H 
Conversation Guide with Participants 
 
Thank you for completing the questionnaires, would you please provide your two best phone numbers so 
that we may contact you and your best contact mailing address.  I have also provided you with an 
addressed and stamped envelope for you to mail your child’s report card to me.  We will send you a 
$25.00 gift card from Target when we receive your child’s report card and we will return you child’s 
report card once we have abstracted the information we need. 
 

28 
 
References: 
 
1. 
Akinbami LJ, Moorman JE, Garbe PL, Sondik EJ. Status of childhood asthma in the United States, 
1980-2007. Pediatrics. Mar 2009;123 Suppl 3:S131-145. 
2. 
Moorman JE, Rudd RA, Johnson CA, et al. National surveillance for asthma--United States, 1980-
2004. MMWR Surveill Summ. Oct 19 2007;56(8):1-54. 
3. 
Teach SJ. www.impact-dc.org. 2010. 
4. 
Kohen DE. Asthma and school functioning. Health reports. Dec 2010;21(4):35-45. 
5. 
Tsakiris A, Iordanidou M, Paraskakis E, et al. The presence of asthma, the use of inhaled steroids, 
and parental education level affect school performance in children. BioMed research 
international. 2013;2013:762805. 
6. 
Hillemeier MM, Gusic ME, Bai Y. Rural and urban children with asthma: are school health 
services meeting their needs? Pediatrics. Sep 2006;118(3):1097-1103. 
7. 
Clark NM, Dodge JA, Thomas LJ, Andridge RR, Awad D, Paton JY. Asthma in 10- to 13-year-olds: 
challenges at a time of transition. Clin Pediatr (Phila). Oct 2010;49(10):931-937.