Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
H S S
EAD  TART  ERVICES FOR 
C W A
HILDREN  ITH  STHMA 
JANET REHNQUIST 
Inspector General 
October 2002 
OEI-09-01-00330  Office of Inspector General

http://oig.hhs.gov 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services (HHS) 
programs, as well as the health and welfare of beneficiaries served by those programs.  This 
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inspections conducted by the following operating components: 
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The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by 
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Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the department, the 
Congress, and the public.  The findings and recommendations contained in the inspections 
reports generate rapid, accurate, and up-to-date information on the efficiency, vulnerability, and 
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The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative 
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control units, which investigate and prosecute fraud and patient abuse in the Medicaid program. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, 
rendering advice and opinions on HHS programs and operations and providing all legal support 
in OIG's internal operations.  The OCIG imposes program exclusions and civil monetary 
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also represents OIG in the global settlement of cases arising under the Civil False Claims Act, 
develops and monitors corporate integrity agreements, develops model compliance plans, 
renders advisory opinions on OIG sanctions to the health care community, and issues fraud 
alerts and other industry guidance.  From Director, Regional Operations 
Office of Evaluation and Inspections 
Subject OIG Memorandum Report: "Head Start Services for Chil&en with Asthma," 
OEI-09-01-00330 
'To 
Wade F. Hom, Ph.D. 
Assistant Secretary for 
Children and Families 
Attached is a memorandum report that assesses the type and level of service that Head Start 
grantees provide to children with asthma. The report is based on a combination of on-site 
reviews of a random sample of health records of children with asthma, interviews with the 
staff, teachers, and parents of children with asthma, and a mail survey administered to a 
random sample of Head Start grantees. 
Our inspection indicates that Hekd Start grantees use a multifaceted approach at school to 
address the needs of children with asthma. Grantees develop asthma management plans and 
administer medication, when necessary. Grantees also train parents, teachers, and children to 
help them manage asthma. Although the Head Start Biireau (the Bureau) has taken steps to 
address asthma, its initiatives could be strengthened. The Bureau's primary initiative has been 
the publication of training guides for Head Start staff. The Bureau collects data on asthma as 
well as many other health conditions, but the data are unreliable because grantees are unsure 
about how to report the health status of children that they serve. Although asthma is the top 
chronic disease among Head Start children, it is one of many serious health conditions affecting 
Head Start children and their families. 
We identified two opportunities for improvement. The Head Start Bureau could consider: 
(1) determining how available resources could better meet the needs of grantees, and 
(2) improving data collection by outlining specific reporting requirements for health statistics. 
You are welcome to provide comments but are not required to do so, since the report contains 
no recommendations. If you have any questions about this report or would like a meeting to 
discuss more detailed information, please have your staff contact Elise Stein, Director, Public 
Health and Human Services at (202) 619-2686. 
Attachment  E X E C U T I V E   S U M M A R Y  
OBJECTIVE 
To assess the type and level of service that Head Start grantees provide to children with 
asthma. 
BACKGROUND 
The Head Start program offers comprehensive early childhood education, nutrition, and health
 
and social services to low-income children from birth to age 5. The program serves
 
approximately 900,000 children through approximately 1,545 grantees. In Fiscal
 
Year (FY) 2001, the budget for Head Start totaled nearly $6.2 billion.  Within the Department
 
of Health and Human Services, the Head Start Bureau (the Bureau), which is part of the
 
Administration for Children, Youth and Families, oversees the program. 
 
Since the creation of Head Start in 1965, comprehensive health services have been an integral
 
part of the program, which aims to improve childrens social competence by providing a
 
broad range of both cognitive and social services. Head Start grantees are subject to extensive
 
requirements, or performance standards, in the area of health. The Head Start Bureau reviews
 
compliance once every 3 years.
 
Asthma is a growing problem for Head Start as well as the nation as a whole. It is the most
 
common chronic disease of childhood and places a disproportionate burden on minority groups
 
and the poor, the populations that Head Start serves.1
 
We determined how Head Start serves children with asthma and their families by reviewing a
 
random sample of childrens health records, interviewing Head Start staff and the parents of
 
children with asthma, and conducting a mail survey of a random sample of Head Start grantees. 
 
We reviewed 245 records and visited a total of 42 grantees, and we mailed surveys to health
 
coordinators at 300 grantees.
 
The findings discussed in this report reflect information gathered from record reviews, on-site
 
interviews, and mail surveys.  We also analyzed grantees medication administration policies.
 
1Department of Health and Human Services, Office of Science Policy, Action Against Asthma: 
A Strategic Plan for the Department of Health and Human Services, May 2000, page 3. 
1
Head Start and Children with Asthma   OEI-09-01-00330  FINDINGS 
Head Start grantees use a multifaceted approach to address the needs of children with 
asthma. Approximately 50 percent of grantees develop asthma plans for all children with 
asthma in their program. In addition, 84 percent of grantees provide education and/or training 
to parents of children with asthma while 55 percent provide education to the children 
themselves.  Some grantees make special efforts to address the needs of children with asthma 
by developing community partnerships to enhance their program and services. 
The Head Start Bureau has taken steps to address asthma, but its initiatives could be 
strengthened. Although the Bureau has responded to the increased prevalence of asthma by 
issuing training guides, grantees do not use them. Furthermore, grantees are not always aware 
of and rarely rely on the resources that the Bureau provides. 
National Head Start data concerning the prevalence of asthma among Head Start 
children are unreliable. The Bureau collects data on a range of health conditions, including 
asthma, but the data are unreliable because grantees are unsure how to report the health status 
of children they serve. Although children have been reported as having asthma, we could not 
find documentation to support reporting for 13 percent of the children. 
Asthma is one of many health conditions affecting Head Start children and their 
families. Most grantees reported that asthma is no more difficult to manage than other health 
conditions that children have, such as dental problems, obesity, and anemia. 
CONCLUSION AND OPPORTUNITIES FOR IMPROVEMENT 
Although asthma affects an increasing number of Head Start children, grantees can meet their needs at 
school by developing management plans, administering medication, and educating children with and 
without asthma, parents, and staff. According to the grantees that we interviewed, asthma is no more 
difficult to manage than other health conditions that Head Start children face. The Administration for 
Children, Youth and Families, which administers Head Start, has tried to address asthma, but it could 
improve the support it provides to grantees. 
The Head Start Bureau could consider: 
C  determining how available resources could better meet the needs of grantees and 
C  improving data collection by outlining specific reporting requirements for health 
statistics. 
2
Head Start and Children with Asthma   OEI-09-01-00330  T A B L E   O F   C O N T E N T S
PAGE
 
EXECUTIVE SUMMARY ...................................................... 1
 
INTRODUCTION ............................................................. 4
 
FINDINGS  .................................................................. 9
 
Addressing the needs of children with asthma  .................................... 9
 
The Head Start Bureaus efforts to address asthma  .............................. 14
 
National Head Start data  .................................................. 15
 
Health conditions affecting Head Start children and their families  ..................... 16
 
CONCLUSION AND OPPORTUNITIES FOR IMPROVEMENT  ................... 17
 
APPENDICES  ............................................................... 
A: Child Record Review Sampling Model  ..................................... 18
 
B: Sample Head Start Materials ............................................. 20
 
Health History Form ................................................ 20
 
Asthma Action Plans  ............................................... 22
 
Medication Administration Policy ...................................... 27
 
Parent Training Flyer  ............................................... 29
 
C: Confidence Intervals for Selected Statistics .................................. 31
 
ACKNOWLEDGMENTS ..................................................... 34
 
3
Head Start and Children with Asthma   OEI-09-01-00330  I N T R O D U C T I O N  
OBJECTIVE 
To determine the type and level of service that Head Start grantees provide to children with 
asthma. 
BACKGROUND 
Head Start Today 
The Head Start program offers comprehensive early childhood education, nutrition, and health 
and social services to low-income children from birth to age 5.  In Fiscal Year (FY) 2001, the 
budget for Head Start totaled nearly $6.2 billion--$6 billion for programs and projects and 
approximately $200 million for support activities. The program serves approximately 900,000 
children, mostly 3- and 4-year olds, through approximately 1,545 grantees. Nearly 80 percent 
of Head Start families have an annual income of less than $15,000, and the head of household 
in 53 percent of Head Start families works full-time. The program serves a multiracial 
population and an estimated 42 percent of eligible children.2 
Health Services in Head Start 
Since the creation of Head Start in 1965, comprehensive health services have been an integral 
part of the program. The health services component reflects Head Starts approach to 
improving childrens social competence (i.e., cognitive, linguistic, social, emotional, and 
physical development).  Head Start programs are required to ensure that each child receives a 
range of health care services, including medical, dental, mental health, and nutritional. The 
program increases access to preventive health services and treatment.  Head Start children are 
more likely to receive medical examinations and treatment than non-Head Start children.3 
2Head Start Bureau, 2002 Head Start Fact Sheet, found at 
<http://www2.acf.dhhs.gov/programs/hsb/research/02_hsfs.htm> April 25, 2002. 
3Zigler, E., Health Services in Head Start, Annual Rev. Pub. Health 15:511-34 (1994). 
4
Head Start and Children with Asthma   OEI-09-01-00330  Performance Standards for Health Services 
In 1975, the Head Start Bureau established performance standards for each component of the 
program: education, parent involvement, social services, and health. In 1996, the Bureau 
revised the standards and issued new requirements for six broad health-related areas: 
determining child health status; developmental, sensory and behavioral screening; extended 
follow-up and treatment; ongoing care; involving parents; and individualization of the program. 
Today, a total of 24 performance standards apply to health services for children with asthma. 
The standards are general and do not refer specifically to asthma or any other health condition. 
Head Start grantees have the discretion to establish their own programs to meet the standards, 
and the Head Start Bureau reviews grantees compliance with all performance standards once 
every 3 years. 
The Growing Problem of Asthma Among Head Start Children and the Head Start 
Bureaus Response 
Asthma is the most common chronic disease of childhood.  The rate of asthma in children under 
the age of 5 has increased more rapidly than the rate for any other age group; in 1999, it was 
estimated that approximately 1.4 million children under the age of 5 have the disease.4 Children 
with asthma under the age of 15 account for approximately 3 million physician visits and nearly 
200,000 hospitalizations each year.5  The estimated annual cost for treating asthma in children 
under 18 is $3.2 billion.6 Asthma can affect the quality of life for children and their families and 
may cause interrupted sleep, limits on activity, disruption of routines, and absences from school. 
Early childhood asthma can be successfully managed. Despite the prevalence of pediatric 
asthma and its potential for adverse impact, the American Academy of Allergy Asthma & 
Immunology (AAAI) reports that expected outcomes of care for children with asthma should 
be high.7 According to AAAI, symptoms can be controlled; the disease can be controlled; 
and activity limitations are not necessary.8 Schools have a significant role to 
4American Academy of Allergy Asthma and Immunology. Pediatric Asthma: Promoting Best 
Practice: Guide for Managing Asthma in Children, 1999, page 2. 
5Id., page 3. 
6American Lung Association. Asthma in Children Fact Sheet, found at 
<http:///www.lungusa.org/asthma/ascpedfac99.html> April 25, 2002. 
7American Academy of Allergy Asthma and Immunology. Pediatric Asthma: Promoting Best 
Practice: Guide for Managing Asthma in Children, 1999, page 3. 
8Id. 
5
Head Start and Children with Asthma   OEI-09-01-00330  play in asthma management, because they are a natural community hub for children and 
families, and thus a good base for asthma education and referral to health care and social 
services.9 Schools also may administer medication to children who need it. 
According to the Head Start Bureau, asthma has been the top chronic disease among Head 
Start children for years, and an estimated 4 percent of all children enrolled in the program 
receive treatment for asthma.10 Asthma places a disproportionate burden on minority groups 
and the poor, the populations that Head Start serves.  The report Action Against Asthma, A 
Strategic Plan for the Department of Health and Human Services notes that low-income 
and minority populations experience substantially higher rates of fatalities, hospital admissions, 
and emergency room visits due to asthma.11 
The Head Start Bureau has attempted to address asthma by issuing two training guides for staff. 
The first guide, Sustaining a Healthy Environment, discusses environmental factors, such as 
second hand smoke, that may trigger asthma. The second guide, Caring for Children with 
Chronic Conditions, contains information on the causes of asthma; how to identify and 
recognize asthma in a preschool setting; sample asthma management plans; and planned 
classroom activities.  In addition to the training guides, a national Head Start Training and 
Technical Assistance Network is available to assist grantees. 
METHODOLOGY 
To meet the objectives of our study, we used a multi-method research approach.  In order to 
obtain a complete picture of what services Head Start provides to children with asthma, we 
conducted (1) an on-site review of a random sample of health records of children with asthma, 
(2) interviews with the staff, teachers, and parents of children with asthma, and (3) a mail 
survey administered to a random sample of Head Start grantees. 
On-site record review and interviews . We developed on-site record review instruments 
and interview guides to determine how grantees identify children with asthma and to assess 
what types of documentation grantees maintain regarding the management of childrens asthma 
at school. We sought information on a number of items including 
9Marielena Lara, MD, MPH et. al., Improving Childhood Asthma Outcomes in the United 
States: A Blueprint for Policy Action, Pediatrics, Vol. 109, No. 5, May 2002, page 921. 
10Head Start Bureau, Head Start Program Information Report for the 2000-2001 Program 
Year, 2002. 
11Department of Health and Human Services, Office of Science Policy, Action Against 
Asthma, A Strategic Plan for the Department of Health and Human Services, May 2000, page 3. 
6
Head Start and Children with Asthma   OEI-09-01-00330  (1) childrens health insurance status, (2) childrens health history, as reported by parents 
and/or physicians, (3) asthma management plans, (4) communication between Head Start staff 
and parents regarding the childrens condition, and (5) medication administration. 
The purpose of the on-site interviews was to obtain additional information about the grantees 
policies and practices related to children with asthma. We interviewed Head Start directors, 
teachers, health services personnel, and parents of children with asthma.  We gathered 
information on several topics including asthma screening, staff training, asthma management 
plans, parental involvement, asthma education and training for parents and children, and 
medication administration. 
We pretested the final record review instruments and interview guides with grantees and 
solicited and received comments from experts and researchers knowledgeable about pediatric 
asthma. 
Sampling methodology for record review.  We used stratified cluster sampling to select the 
children whose records we reviewed. We chose this sampling methodology because we 
wanted to project our findings to the entire population of children with asthma enrolled in the 
Head Start program.  We grouped all children in the Head Start program into geographic 
clusters based on the zip code of the program they attended.  Each cluster contained 
approximately 15 children with asthma.  We then randomly selected 15 of these clusters in 
three geographic strata: 3 clusters from the western United States, 5 clusters from the central 
United States, and 7 clusters from the eastern United States.  Within each sample cluster, we 
reviewed the records of all children with asthma.  Our sample consisted of 258 children with 
asthma. We reviewed records for 245 of these children (95 percent of the total), and we 
visited a total of 42 grantees. Appendix A contains a more detailed explanation of the child 
record review sampling methodology. 
CLUSTER SAMPLE OF CHILDREN 
Number of 
Strata  Cluster  Clusters 
Universe  Selected 
Western U.S.  531  3 
Central U.S.  886  5 
Eastern U.S.  1257  7 
Record reviews allow researchers to view and assess the documentation and other information 
maintained by respondents. While records provide useful information on practices and 
performance, the quality of records can be affected by resource constraints. 
7
Head Start and Children with Asthma   OEI-09-01-00330  The usefulness of record reviews may be limited if records do not accurately reflect 
respondents procedures. 
Mail survey. The mail survey was designed to provide descriptive information on grantees 
policies and procedures related to children with asthma. The survey solicited information on the 
same topics included in the on-site interviews.  In addition, we analyzed medication 
administration policies submitted by grantees. We pretested the mail survey and solicited 
feedback from Head Start grantees. 
Sampling methodology for mail survey. We selected 300 grantees by using a stratified 
sample.  We selected this methodology because we wanted to ensure that we would collect 
information from grantees that have experience caring for children with asthma. Using the 
Program Information Report (PIR) data from the 2000-2001 school year, we grouped grantees 
into three strata based on the number of children with asthma in their program.  The first stratum 
consisted of the 100 grantees with the most children with asthma. The second stratum 
consisted of the 25 percent of the remaining grantees with the most children with asthma.  The 
third stratum consisted of all remaining grantees.  Our response rate for the mail survey was 87 
percent (262/300). 
MAIL SURVEY SAMPLE 
Number of children 
Strata  Grantee  with asthma per  Grantees 
Universe  program  Selected 
Stratum I  100  70 or more  100 
Stratum II  605  17 to 70  100 
Stratum III  1813  fewer than 17  100 
TOTAL  2513  300 
Our review was conducted in accordance with the Quality Standards for Inspections issued 
by the Presidents Council on Integrity and Efficiency. 
8
Head Start and Children with Asthma   OEI-09-01-00330  F I N D I N G S  
We used a combination of record reviews, on-site interviews, and mail surveys to determine 
how Head Start grantees serve children with asthma. We found that grantees meet the needs 
of children with asthma by developing written action plans, administering medication, and 
educating and training children, parents, and staff. The Head Start Bureau has attempted to 
support grantees and collect data on the health status of children, but its efforts could be 
strengthened and its data are unreliable. 
Head Start grantees use a multifaceted approach to address 
the needs of children with asthma 
Grantees consistently conduct initial health assessments during which parents 
disclose if their child has asthma 
According to program performance standards, Head Start grantees are required to request 
information about the childs overall health condition from the childs parent.12 Grantees 
consistently gather this information before school begins and compile a health history for the 
child (See Appendix B).  We found that 94 percent of childrens records contained a copy of 
the childs health history, which includes information about everything from prenatal care to 
current health conditions.  Nearly 80 percent of the records we reviewed showed that the 
parent had reported the childs asthma to the grantee during the initial assessment. 
Performance standards also require grantees to obtain documentation related to the childs 
current health status from a physician or other health professional.13 We found evidence of 
physician14 diagnosis in only 44 percent of the records we reviewed. However, grantees 
request information from a physician when a child takes medication at school. Staff interviewed 
during our on-site record review provided their own explanations for the lack of physician 
documentation. The most common explanations were: difficulty obtaining information from 
physicians; lack of parental effort to obtain requested documentation; and misplaced or lost 
documents from records. 
12Program Performance Standards for Operation of Head Start Programs by Grantees and 
Delegate Agencies, 45 C.F.R.  1304.22(b)(3). 
1345 C.F.R.  1304.20(a)(1)(ii) (2002). 
14Throughout this report, the term parent may refer to: parent(s); other family members; other 
caregivers; and/or legal guardians. 
9
Head Start and Children with Asthma   OEI-09-01-00330  Grantees address the needs of children with asthma by developing management 
plans and administering medication when necessary 
Asthma Management Plans. Grantees play a critical role in asthma management because 
children now spend more time at school. 
According to national Head Start statistics, the 
The present asthma program 
number of Head Start families requiring full-day, 
available to our centers has 
full-year child care for their enrolled child has 
demonstrated a reduction in sick 
increased significantly. According to one grantee  time and days missed.  The 
we visited, Welfare reform has had a significant  childrens asthma is much 
impact on our families. Ten years ago, before  improved and the children are 
welfare reform, approximately 60 percent of our  learning how to manage their 
asthma at home and at the center. 
families were working; now its approximately 85 
The program has made a dramatic 
percent. 
difference to our children. 
Head Start Grantee 
Asthma management plans are one component of 
grantees efforts to manage asthma.  These plans 
are documents that may identify the early warning signs of an asthma episode, the medications 
that a child uses and instructions for administering them, and when to contact the physician or 
emergency room (see Appendix B for examples of plans used by Head Start grantees). The 
development of an asthma management plan is part of one of the four key components 
identified by the National Asthma Education and Prevention Program (NAEPP) of the National 
Heart Lung and Blood Institute (NHLBI) for long-term control of persistent asthma in 
children.15 By developing plans, Head Start grantees meet the performance standard which 
requires that they develop and implement a follow-up plan for identified conditions.16 
Approximately 48 percent of grantees indicate that they develop written asthma management 
plans for all children with asthma in their program. Among those grantees that do not develop 
plans for all children with asthma, many report that they develop plans for children under 
specific circumstances.  For example, grantees may develop plans for children who take 
medication at school, children with severe asthma, or children with physical and/or dietary 
restrictions. 
One grantee that we visited has developed an asthma protocol to identify the children who need 
an asthma management plan. After identifying children with active asthma who take medication 
at school, the grantee works with the childs parent and physician to 
15National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. 
Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. National Institute 
of Health pub no 97-4051. Bethesda, MD, 1997. 
1645 C.F.R.  1304.20(a)(1)(iv). 
10
Head Start and Children with Asthma   OEI-09-01-00330  develop an appropriate plan. For children who either have active asthma, but do not take
 
medication at school, or children who do not have active asthma, but who have had a history of
 
the disease, the grantee will note them on a health alert list that is posted in every classroom.
 
We found asthma management plans in 30 percent of the records that we reviewed. 
 
While we did not consistently probe as to the reason the plan might be absent from the childs
 
record, several of the staff members we interviewed offered the following explanations: the
 
grantee does not develop action plans for any of their children; the child had asthma before
 
entering the program, but does not exhibit any symptoms now; parents fail to return information
 
to the program, so the plan cannot be completed; or the grantee only develops plans for
 
children who meet certain criteria, including: children with activity restrictions, children who take
 
medication at school, or children whose asthma is severe.
 
Medication Administration.  Grantees are required to establish and maintain written
 
medication administration procedures.17 We found that grantees meet this requirement and are
 
prepared to deliver medication to children who need it.  Most grantees (85 percent) that
 
responded to the mail survey report that their staff are authorized to administer medication to
 
children with asthma. We reviewed written policies and found that staff often administer
 
medication after receiving written orders from the childs physician and instructions from the
 
parent (see Appendix B for a sample medication administration policy).
 
Although grantees are prepared to administer medication, children with asthma often do not
 
need it.  One grantee reported, while we do have a plan for each child with asthma, we rarely
 
need to administer medication at school. We found that at least 53 percent of children with
 
asthma do not receive medication at school. One possible explanation is that parents administer
 
medication at home. When children need medication, the typical drug is albuterol.18 Of the
 
children we could determine took medication at school, approximately 91 percent took
 
albuterol. 
 
An integral part of Head Starts plan for managing children with asthma is 
education, training, and parent involvement 
Patient Education.  Approximately 55 percent of grantees provide some type of education 
and training to children with asthma.  According to NAEPP, patient education is an essential 
component of successful asthma management.19 In order to learn how to manage the disease, 
every child with asthma should receive the appropriate information about their condition. 
According to experts, children as young as 2 years old can begin 
1745 C.F.R.  1304.22(c) (2002).
 
18Albuterol is a quick relief medication, taken, as needed, to relieve symptoms.
 
19See Supra note 15.
 
11
Head Start and Children with Asthma   OEI-09-01-00330  learning about their asthma.20 While more than half of grantees report they provide some form 
of training and education to children with asthma, the topics they cover are varied. Of the 
grantees that educate children with asthma, 53 percent teach children about their symptoms, 44 
percent teach children what to do during an asthma emergency, and 33 percent teach children 
how to administer medication. 
Some grantees have developed innovative approaches to educate children with asthma about 
their disease. One grantee that we visited had developed an asthma prevention program as a 
pilot project in 1995 after discovering that 37 percent of enrolled children had asthma. 
According to program materials, most families who began the program completed it.  All of the 
families reported a marked improvement in their childs asthma.  This program includes special 
learning activities at school to teach children about their bodies, respiration, and asthma triggers. 
In addition, the program distributes an asthma kit to each child.  The kit includes a peak flow 
meter (a device that measures the ability to exhale) and costs $40 initially and $25 a year to 
maintain. 
Education of Children without Asthma. Asthma management also may involve education of 
children who do not have asthma.  Of the 37 percent of grantees that provide education and 
training to children without asthma, several show children a video developed by the American 
Lung Association and the Childrens Television Workshop. This video, entitled A is for 
Asthma, features Sesame Street characters teaching children about the disease and how to 
help someone who has trouble breathing. The A is for Asthma program also includes a 
companion guide for caregivers as well as suggested classroom activities. Both the video and 
the guide are available in English and Spanish. 
Parent Education and Involvement. Head Start programs are required to involve parents in 
the care that their children receive at school. One performance standard requires grantees to 
establish a system of ongoing communication with parents of children with identified health 
needs to facilitate the implementation of the follow-up plan.21 Grantees also must familiarize 
parents with use of and rationale for all health and developmental procedures administered 
through the program or contract.22 We found that 84 percent of grantees provide education 
and/or training to parents of children with asthma (See Appendix B for a sample flyer related to 
parent training).  One grantee reported, parents and staff together receive the same training to 
ensure that the treatment is administered correctly.  Among the grantees that educate and train 
parents, 74 percent provide information about recognizing symptoms of an asthma attack. 
20American Academy of Allergy Asthma and Immunology, Pediatric Asthma: Promoting Best 
Practices: Managing the Child with Asthma, Component 4, page 105, found at 
<http://www.aaai.org/members/resources/initiatives/pediatricasthmaguidelines/default.htm> April 4, 2002. 
2145 C.F.R.  1304.20(C)(1) (2002). 
2245 C.F.R.  1304.20(e)(2) (2002). 
12
Head Start and Children with Asthma   OEI-09-01-00330  Grantees also provide training on what to do during an asthma emergency and how to 
administer asthma medications.  In addition, parents participate in the development of asthma 
management plans. Almost two-thirds (65 percent) of grantees report that they involve parents 
in the development of these plans. 
One grantee we visited used a parent education program specifically developed for parents of 
preschoolers with asthma. The program, known as Wee Wheezers, features a broad 
curriculum designed to teach parents how to recognize their childs symptoms, administer 
medication appropriately, and communicate effectively with physicians and other adults who are 
responsible for the childs care. The program consists of four 2-hour sessions. 
In some cases, parents and Head Start staff communicate with each other about childrens 
condition at school. Based on our review of the records of children with asthma, we found that 
39 percent of staff have had some type of contact with parents of children with asthma 
regarding their childrens condition. Typically, parents of children with asthma and staff interact 
when children have asthma-related difficulties at school; children are absent due to their asthma 
condition; or staff need information about medication administration and/or school emergencies. 
Staff Training. Most grantees (90 percent) provide 
asthma-related training to staff.  Head Start staff must have 
adequate training on how to care for children with asthma.23  ...when a child has 
asthma, the parent is the 
Grantees are required to establish and implement a 
primary educator. 
structured approach to staff training and development.24 
Parents will train staff on 
Grantees should develop and integrate asthma-related 
the specific, individual 
training to cover topics, such as recognizing the symptoms 
needs of their child. 
of asthma, the procedures for handling an asthma 
emergency and how to administer asthma medications.25 
Approximately 95 percent of grantees that educate their 
staff  provide training on how to recognize the symptoms of asthma and what to do during an 
asthma emergency, and 85 percent train staff on how to administer medication. 
23National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. 
National Asthma Education and Prevention Program Resolution on Asthma Management at 
School. found at <http://www.nhlbi.nih.gov/health/public/lung/asthma/resolut.htm> April 3, 2002. 
2445 C.F.R.  1304.52(k)(2) (2002). 
25See Supra note 23. 
13
Head Start and Children with Asthma   OEI-09-01-00330  Some Head Start grantees develop community partnerships to help them address 
the needs of children with asthma 
Some grantees work with universities on asthma-related research projects. One grantee we 
visited is involved in a 3-year asthma project sponsored by a local university. The first and 
second years focused on expanded screening.  Nursing students administered physical exams at 
home or school to children with asthma or children using asthma medications. The third year 
will focus on parent education. Another grantee works with a local university on a project 
designed to identify children suspected of having asthma and refer them to appropriate medical 
care when needed.  One grantee reported how beneficial it was to work with a local university 
on a grant on asthma and Head Start children. The grantee stated, we are fortunate to have 
the expertise and knowledge from the university to help us in all areas of programming  staff 
education, parent training, and developing management plans. 
A grantee that responded to our mail survey obtained a $65,000 grant from the philanthropic 
arm of a major pharmaceutical company to fund an outreach project for children with asthma or 
at risk for asthma, their parents, and staff at 40 Head Start sites.  The funding supported 
multilingual screening and education activities.  The program involved over 3,700 Head Start 
children, 62 parents, and 170 staff members. 
The Head Start Bureau has taken steps to address asthma, 
but its initiatives could be strengthened 
The Bureau has issued training guides to support grantees 
In the mid-1990's, the Head Start Bureau contracted with a private company to develop 
health-related training guides for staff.  The company wrote a series of eight guides between 
1995 and 2000. Two of these guides relate to asthma. The first guide, Sustaining a Healthy 
Environment, discusses ways to promote health at home and at school. The second guide, 
Caring for Children with Chronic Conditions, addresses asthma specifically and contains 
guidelines for developing health plans for children with the disease. Both guides are available in 
English only. 
Grantees are not always aware of and rarely rely on Head Start Bureau resources 
to help them address the needs of children with asthma 
Only 37 percent of grantees use the Head Start Bureaus training guide, Caring for Children 
with Chronic Conditions, which teaches Head Start staff how to care for children with asthma 
and other chronic health conditions. A grantee reported, I do not recall receiving the Head 
Start Bureaus training guide, nor have I received any technical assistance or training regarding 
asthma . . . we use the resources that are available to us. 
14
Head Start and Children with Asthma   OEI-09-01-00330  Most grantees do not use the National Head Start
 
Training and Technical Assistance Network for 
 
assistance regarding children with asthma. The network 
 
We have more children 
consists of regional Quality Improvement Centers staffed by
  diagnosed with asthma 
specialists familiar with local cultures and  issues.  Asthma
  than any other health 
has not been a priority for the network, although health
  condition.  I would like 
specialists are available to assist grantees. Almost 85
  more information from the 
Training and Technical 
percent of grantees reported that they do not use the
 
Assistance Network 
network for assistance regarding asthma.
 
National Head Start data concerning the prevalence of 
asthma among Head Start children are unreliable 
Head Start prevalence data provide an inaccurate, incomplete picture of the impact of asthma 
on Head Start programs.  The Program Information Report (PIR), the annual survey of 
grantees, reflects inconsistent reporting on the prevalence of asthma and other health conditions. 
According to the Head Start  Bureau, the PIR provides comprehensive, national data on the 
Head Start program . . .the number of children 
being served and program services and 
We struggle with whom to count 
activities.26 However, grantees receive little 
as having asthma.  There is no 
guidance from the Head Start Bureau on how 
clear definition from ACF and we 
to report the number of children with asthma in  have to make up our own. Kids 
their programs.  The PIR form only directs  who have been diagnosed with 
grantees to report the number of children who  asthma, but dont exhibit any 
received treatment for asthma.  symptoms get lost in the group 
When asked whom they report as having 
asthma for purposes of the PIR, grantees responded with a variety of answers. Overall, Head 
Start grantees identified 10 different criteria for reporting the number of children with asthma on 
the PIR. In some cases grantees only report those children who were diagnosed by a health 
care practitioner, while other grantees are more inclusive and report based on a combination of 
criteria, including those who been diagnosed by a health care practitioner and those who were 
identified through parent reporting. During our review, we identified some children 
(13 percent) who had been reported on the PIR as having asthma, but whose records 
contained no evidence of the condition. 
26Head Start Bureau, Information Memorandum1997-1998 Program Information Report, 
March 18, 1998. 
15
Head Start and Children with Asthma   OEI-09-01-00330  GRANTEES REPORT ASTHMA CASES DIFFERENTLY
Children identified Children diagnosed by a Children receiving Percent of
through parent reporting health care practitioner medication at school Grantees*
U U U 34 percent
U 30 percent
U U 19 percent
U U 10 percent
                                             Source:  Office of Evaluation and Inspections, 2002
*Note: 7 percent of grantees use other, less common criteria for reporting their asthma cases. 
Asthma is one of many health conditions affecting Head Start
children and their families
Almost two-thirds (65 percent) of all Head Start grantees reported that there is at least one
other health condition they consider to be a health priority in addition to asthma.  In all, grantees
identified over 50 different health conditions that affect the children in their program.  In fact,
according to 86 percent of all grantees, asthma is no more difficult to manage than any of the
health conditions that children in their
program have.  After being asked if
OTHER HEALTH PRIORITIES IN HEAD
there were any other health priorities in
START
their program, one grantee responded
All of our health conditions are a
priority. . . . they are too numerous to
state each one.  Some of the more
common conditions that Head Start
grantees noted include obesity, dental
problems, anemia, seizures, and high
lead levels.
Source:  Office of Evaluation and Inspections, 2002
16
Head Start and Children with Asthma                                                                                                              OEI-09-01-00330 CONCLUSION  AND  OPPORTUNITIES FOR IMPROVEMENT
CONCLUSION 
Although asthma affects an increasing number of Head Start children, grantees can meet their 
needs at school by developing management plans, administering medication, and educating 
children with and without asthma, parents, and staff.  According to grantees we interviewed, 
asthma is no more difficult to manage than other health conditions that Head Start children face. 
The Administration for Children, Youth and Families, which administers Head Start, has tried to 
address asthma, but it could improve the support it provides to grantees. 
OPPORTUNITIES FOR IMPROVEMENT 
Determine how available resources could better meet the needs of 
grantees 
Grantees do not typically use the Training and Technical Assistance Network or the training 
guide that specifically addresses asthma.  Grantees have found other resources to assist children 
with asthma and their families. These resources include health guides written in English as well 
as Spanish. Instead of paying for special training guides for the Head Start community, the 
Bureau could disseminate information that has been developed by a myriad of private and 
public entities. 
Improve data collection by outlining specific reporting criteria for 
health statistics 
Since data on the health status of children drive national policy, the Head Start Bureau could 
improve the accuracy of this data by outlining criteria for reporting children who have various 
health conditions. For example, if the Bureau decides that parent reporting is adequate, it could 
instruct grantees to include in the PIR the number of children whose parents reported that their 
children have asthma. 
17
Head Start and Children with Asthma   OEI-09-01-00330  Appendix A 
Child Record Review Sampling Model
 
Head Start Cluster Sample 
To select the childrens records for our review, we used a one-stage cluster sample.  Each 
cluster was generated by grouping children together based on the zip code of the grantee to 
which they were enrolled. Clusters consisted of children enrolled in the Head Start program 
during the 2000-2001 school year. We designed these clusters so that they would each contain 
approximately 15 children who were being treated for asthma. 
Since at the time of the sample selection the 2000-2001 PIR was not available, we used the 
1999-2000 PIR to create the cluster framework and develop probabilities that children from 
each Head Start program would be included in a given cluster.  Specifically, we developed a 
computer model that simulated a clustering of children with asthma from the PIR. The 
probability that a specific child at a specific grantee would later be included in a given cluster 
was determined by dividing the number of that grantees PIR children with asthma in that cluster 
by the overall total number of children with asthma in that grantee. 
Since some grantees did not have any children being treated for asthma in the 1999-2000 
school year, but might during the 2000-2001 school year, we assigned these grantees to the 
cluster closest to them geographically. 
We then randomly selected 15 of these clusters in three geographic strata: 3 from the western 
U.S., 5 from the central U.S., and 7 from the eastern U.S. We asked the Head Start programs 
in our sample clusters for the number of children enrolled during the 2000-2001 school year 
and for a list of the names of the children who had been treated for asthma.  Because each 
grantees children were divided among 1 or more clusters, we randomly assigned these children 
to clusters according to the probabilities that we developed using the PIR computer model. 
We then conducted site visits to the grantees whose children with asthma appeared in the 
clusters in our sample. 
Example 
Grantee X had 200 children enrolled and 10 children being treated for asthma, according to the 
1999-2000 PIR.  Our computer model clusters 3 of the children with asthma into cluster A and 
7 into cluster B. During our cluster selection, we randomly select cluster A.  We request from 
grantee X the total number of children enrolled and a list of the names 
18
Head Start and Children with Asthma   OEI-09-01-00330  of children being treated for asthma during the 2000-2001 program year. Grantee X reports a 
total enrollment of 100 children and sends us a list of the names of 20 children who were being 
treated for asthma. 
We then randomly assign these 100 children to the two clusters, with probability 3/10 for 
cluster A and 7/10 for cluster B. Therefore, we would expect approximately 6 children with 
asthma to be included in cluster A for this grantee. We then review the records of these 
children with asthma. 
19
Head Start and Children with Asthma   OEI-09-01-00330  Appendix B 
Sample Head Start Materials
 
20
Head Start and Children with Asthma   OEI-09-01-00330  21
Head Start and Children with Asthma   OEI-09-01-00330  22
Head Start and Children with Asthma   OEI-09-01-00330  23
Head Start and Children with Asthma   OEI-09-01-00330  24
Head Start and Children with Asthma   OEI-09-01-00330  25
Head Start and Children with Asthma   OEI-09-01-00330  26
Head Start and Children with Asthma   OEI-09-01-00330  27
Head Start and Children with Asthma   OEI-09-01-00330  28
Head Start and Children with Asthma   OEI-09-01-00330  29
Head Start and Children with Asthma   OEI-09-01-00330  30
Head Start and Children with Asthma   OEI-09-01-00330  Appendix C 
Confidence Intervals for Selected Statistics
 
The following tables show the point estimates and 95 percent confidence intervals for selected 
statistics in the order that they appear in the report. 
Point  95 Percent 
Statistic 
Estimate  Confidence Interval 
Percent of records that contained a health history form  94%  89%-100% 
Percent of records that contained documentation of parent-
80%  73%-87% 
reported asthma 
Percent of records that contained documentation of asthma 
44%  34%-54% 
diagnosed by health care practitioner 
Percent of grantees that develop written management plans 
48%  40%-56% 
for all children with asthma in their program 
Percent of grantees that develop plans for children with 
17%  11%-23% 
asthma who take medication at school 
Percent of grantees that develop plans for children with 
8%  3%-12% 
asthma who have active and/or severe asthma 
Percent of grantees that develop plans for children with 
3%  1%-6% 
asthma who have physical and/or dietary restrictions 
Percent of records that contained a copy of an asthma 
30%  15%-44% 
management plan 
Percent of grantees that have authorized staff to deliver 
85%  79%-90% 
medication to children with asthma while they are at school 
Percent of children with asthma who do not receive 
53%  37%-68% 
medication while they are at school 
Of children with asthma who take medication while they are 
91%  75%-100% 
at school, percent who take albuterol 
Percent of grantees that provide education or training on 
55%  46%-63% 
asthma to children with asthma 
Of the grantees that provide training and education on asthma 
to children with asthma, percent who teach them about  53%  41%-65% 
recognizing symptoms of an asthma attack 
31
Head Start and Children with Asthma   OEI-09-01-00330  Of the grantees that provide training and education on asthma 
to children with asthma, percent who teach them about what  44%  32%-55% 
to do during an asthma emergency 
Of the grantees that provide training and education on asthma 
to children with asthma, percent who teach them about  33%  22%-44% 
administering asthma medication 
Percent of grantees that provide education or training on 
37%  28%-46% 
asthma to children without asthma 
Percent of grantees that provide education or training on 
84%  77%-89% 
asthma to parents of children with asthma 
Of the grantees that provide education or training on asthma 
to parents of children with asthma, percent who teach them  74%  66%-82% 
about recognizing symptoms of an asthma attack 
Percent of grantees that involve parent in the development of 
65%  57%-73% 
asthma management plans 
Percent of records that have documentation of contact 
between parents of children with asthma and the program  39%  26%-52% 
about the childs condition 
Percent of grantees that provide education or training on 
90%  86%-95% 
asthma to Head Start staff 
Of the grantees that provide education or training on asthma 
to Head Start staff, percent that teach them about recognizing  96%  93%-100% 
symptoms of an asthma attack 
Of the grantees that provide education or training on asthma 
to Head Start staff, percent that teach them about what to do  95%  91%-99% 
during an asthma emergency 
Of the grantees that provide education or training on asthma 
to Head Start staff, percent that teach them about how to  85%  79%-91% 
administer asthma medication 
Percent of grantees that use the Head Start Bureaus training 
guide, Caring for Children with Chronic Conditions,  37%  29%-44% 
Module 3 
Percent of grantees that have not received assistance on 
asthma from the Head Start Training and Technical  84%  79%-89% 
Assistance Network 
Percent of children who were identified as having asthma, but 
13%  8%-17% 
whose records contain no mention of the condition 
32
Head Start and Children with Asthma   OEI-09-01-00330  Percent of grantees that use a combination of parent 
reporting, physician diagnosis, and receiving asthma 
34%  26%-41% 
medication at school as the criteria for reporting children with 
asthma on the Program Information Report 
Percent of grantees that use physician diagnosis as the only 
criterion for reporting children with asthma on the Program  30%  23%-37% 
Information Report 
Percent of grantees that use a combination of parent reporting 
and physician diagnosis as the criteria for reporting children  19%  13%-26% 
with asthma on the Program Information Report 
Percent of grantees that use a combination of physician 
diagnosis and receiving asthma medication at school as the 
10%  6%-15% 
criteria for reporting children with asthma on the Program 
Information Report 
Percent of grantees that reported there is at least one other 
health condition they consider to be a health priority in addition  65%  57%-72% 
to asthma 
Percent of grantees that reported that asthma is no more 
difficult to manage than any of the health conditions that  86%  81%-91% 
children in their program have 
Percent of grantees that report that dental health is another 
16%  10%-21% 
health priority for their program 
Percent of grantees that report that obesity is another health 
14%  9%-19% 
priority for their program 
Percent of grantees that report that anemia is another health 
14%  8%-19% 
priority for their program 
Percent of grantees that report that allergies are another 
12%  7%-17% 
health priority for their program 
Percent of grantees that report that seizures are another 
11%  7%-16% 
health priority for their program 
Percent of grantees that report that lead levels are another 
7%  3%-10% 
priority for their program 
Note: In the tables above, point estimates and confidence intervals are rounded to the nearest percentage 
point. 
33
Head Start and Children with Asthma   OEI-09-01-00330  ACKNOWLEDGMENTS 
This report was prepared under the direction of Paul Gottlober, Regional Inspector General for 
Evaluation and Inspections in the San Francisco Regional Office. Other principal Office of Evaluation 
and Inspections staff who contributed include: 
Cindy Lemesh, Project Leader

Christopher Tarbell, Program Analyst

Barbie Robinson, Program Analyst

Camille Harper, Program Analyst

Robert Gibbons, Program Analyst

Steven Zerebecki, Program Analyst

Steve Milas, Program Analyst

Alan Levine, Program Specialist

For information or copies of this report, please contact the Office of Inspector Generals Public Affairs 
office at (202) 619-1343.