Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JANET REHNQUIST 

Inspector General 

October 2002 

OEI-09-01-00330 

HEAD START SERVICES FOR 

CHILDREN WITH ASTHMA 
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 

statutory mission is carried out through a nationwide network of audits, investigations, and 

inspections conducted by the following operating components: 

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conducting audits with its own audit resources or by overseeing audit work done by others. 

Audits examine the performance of HHS programs and/or its grantees and contractors in 

carrying out their respective responsibilities and are intended to provide independent 

assessments of HHS programs and operations in order to reduce waste, abuse, and 

mismanagement and to promote economy and efficiency throughout the department. 

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 

effectiveness of departmental programs. 

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The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative 

investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 

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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 

penalties on health care providers and litigates those actions within the department. The OCIG 

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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 
EXECUTIVE SUMMARY 

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 children’s “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 children’s 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.
 

1

Department 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. 

Head Start and Children with Asthma 1 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. 

Head Start and Children with Asthma 2 OEI-09-01-00330 
TABLE OF CONTENTS

PAGE
 

EXECUTIVE SUMMARY ...................................................... 1
 

INTRODUCTION ............................................................. 4
 

FINDINGS .................................................................. 9
 

Addressing the needs of children with asthma .................................... 9
 

The Head Start Bureau’s 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
 

Head Start and Children with Asthma 3 OEI-09-01-00330 
INTRODUCTION 

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 Start’s approach to 

improving children’s “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 

2

Head Start Bureau, 2002 Head Start Fact Sheet, found at 

<http://www2.acf.dhhs.gov/programs/hsb/research/02_hsfs.htm> April 25, 2002. 

3

Zigler, E., Health Services in Head Start, Annual Rev. Pub. Health 15:511-34 (1994). 

Head Start and Children with Asthma 4 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 

Bureau’s 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 

4

American Academy of Allergy Asthma and Immunology. “Pediatric Asthma: Promoting Best 

Practice: Guide for Managing Asthma in Children,” 1999, page 2. 

5

Id., page 3. 

6

American Lung Association. “Asthma in Children Fact Sheet,” found at 

<http:///www.lungusa.org/asthma/ascpedfac99.html> April 25, 2002. 

7

American Academy of Allergy Asthma and Immunology. “Pediatric Asthma: Promoting Best 

Practice: Guide for Managing Asthma in Children,” 1999, page 3. 

8

Id. 

Head Start and Children with Asthma 5 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 children’s asthma 

at school. We sought information on a number of items including 

9

Marielena 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. 

Head Start and Children with Asthma 6 OEI-09-01-00330 
(1) children’s health insurance status, (2) children’s health history, as reported by parents 

and/or physicians, (3) asthma management plans, (4) communication between Head Start staff 

and parents regarding the children’s 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 

Strata Cluster 

Universe 

Number of 

Clusters 

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. 

Head Start and Children with Asthma 7 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 

Strata Grantee 

Universe 

Number of children 

with asthma per 

program 

Grantees 

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 President’s Council on Integrity and Efficiency. 

Head Start and Children with Asthma 8 OEI-09-01-00330 
FINDINGS 

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 child’s overall health condition from the child’s 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 children’s records contained a copy of 

the child’s 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 child’s asthma to the grantee during the initial assessment. 

Performance standards also require grantees to obtain documentation related to the child’s 

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. 

Head Start and Children with Asthma 9 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 

number of Head Start families requiring full-day, 

full-year child care for their enrolled child has 

increased significantly. According to one grantee 

we visited, “Welfare reform has had a significant 

impact on our families. Ten years ago, before 

welfare reform, approximately 60 percent of our 

families were working; now it’s approximately 85 

percent.” 

Asthma management plans are one component of 

grantees’ efforts to manage asthma. These plans 

“The present asthma program 

available to our centers has 

demonstrated a reduction in sick 

time and days missed. The 

children’s asthma is much 

improved and the children are 

learning how to manage their 

asthma at home and at the center. 

The program has made a dramatic 

difference to our children.” 

Head Start Grantee 

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 child’s 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). 

Head Start and Children with Asthma 10 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 child’s
 

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 child’s 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 Start’s 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.
 

Head Start and Children with Asthma 11 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 child’s 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 Children’s 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). 

Head Start and Children with Asthma 12 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 child’s symptoms, administer 

medication appropriately, and communicate effectively with physicians and other adults who are 

responsible for the child’s care. The program consists of four 2-hour sessions. 

In some cases, parents and Head Start staff communicate with each other about children’s 

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 children’s 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 

Grantees are required to establish and implement a 

structured approach to staff training and development.24 

Grantees should develop and integrate asthma-related 

training to cover topics, such as recognizing the symptoms 

of asthma, the procedures for handling an asthma 

emergency and how to administer asthma medications.25 

Approximately 95 percent of grantees that educate their 

“...when a child has 

asthma, the parent is the 

primary educator. 

Parents will train staff on 

the specific, individual 

needs of their child.” 

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. 

Head Start and Children with Asthma 13 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 Bureau’s 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 Bureau’s training guide, nor have I received any technical assistance or training regarding 

asthma . . . we use the resources that are available to us.” 

Head Start and Children with Asthma 14 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 
 

consists of regional Quality Improvement Centers staffed by
 

specialists familiar with local cultures and issues. Asthma
 

has not been a priority for the network, although health
 

specialists are available to assist grantees. Almost 85
 

percent of grantees reported that they do not use the
 

network for assistance regarding asthma.
 

“We have more children 

diagnosed with asthma 

than any other health 

condition. I would like 

more information from the 

Training and Technical 

Assistance Network” 

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 

activities.”26 However, grantees receive little 

guidance from the Head Start Bureau on how 

to report the number of children with asthma in 

their programs. The PIR form only directs 

grantees to report “the number of children who 

received treatment for asthma.” 

When asked whom they report as having 

“We struggle with whom to count 

as having asthma. There is no 

clear definition from ACF and we 

have to make up our own. Kids 

who have been diagnosed with 

asthma, but don’t exhibit any 

symptoms get lost in the group 

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 Memorandum–1997-1998 Program Information Report,” 

March 18, 1998. 

Head Start and Children with Asthma 15 OEI-09-01-00330 
Head Start and Children with Asthma 16 OEI-09-01-00330

Source: 

OTHER HEALTH PRIORITIES IN HEAD

START

GRANTEES REPORT ASTHMA CASES DIFFERENTLY

Children identified

through parent reporting

Children diagnosed by a

health care practitioner

Children receiving

medication at school

Percent of

Grantees*

U U U 34 percent

U 30 percent

U U 19 percent

U U 10 percent

 Source: 

*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. 

identified over 50 different health conditions that affect the children in their program. 

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. 

there were any other health priorities in

their program, one grantee responded

“All of our health conditions are a

priority. . . . they are too numerous to

state each one.” 

common conditions that Head Start

grantees noted include obesity, dental

problems, anemia, seizures, and high

lead levels.

Office of Evaluation and Inspections, 2002

Office of Evaluation and Inspections, 2002

In all, grantees

In fact,

After being asked if

Some of the more
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. 

Head Start and Children with Asthma 17 OEI-09-01-00330 
Appendix A 

Child Record Review Sampling Model
 

Head Start Cluster Sample 

To select the children’s 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 grantee’s 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 

grantee’s 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 

Head Start and Children with Asthma 18 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. 

Head Start and Children with Asthma 19 OEI-09-01-00330 
Appendix B 

Sample Head Start Materials
 

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Head Start and Children with Asthma 30 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. 

Statistic Point 

Estimate 

95 Percent 

Confidence Interval 

Percent of records that contained a “health history” form 94% 89%-100% 

Percent of records that contained documentation of parentreported asthma 80% 73%-87% 

Percent of records that contained documentation of asthma 

diagnosed by health care practitioner 44% 34%-54% 

Percent of grantees that develop written management plans 

for all children with asthma in their program 48% 40%-56% 

Percent of grantees that develop plans for children with 

asthma who take medication at school 17% 11%-23% 

Percent of grantees that develop plans for children with 

asthma who have “active” and/or “severe” asthma 8% 3%-12% 

Percent of grantees that develop plans for children with 

asthma who have physical and/or dietary restrictions 3% 1%-6% 

Percent of records that contained a copy of an asthma 

management plan 30% 15%-44% 

Percent of grantees that have authorized staff to deliver 

medication to children with asthma while they are at school 85% 79%-90% 

Percent of children with asthma who do not receive 

medication while they are at school 53% 37%-68% 

Of children with asthma who take medication while they are 

at school, percent who take albuterol 91% 75%-100% 

Percent of grantees that provide education or training on 

asthma to children with asthma 55% 46%-63% 

Of the grantees that provide training and education on asthma 

to children with asthma, percent who teach them about 

recognizing symptoms of an asthma attack 

53% 41%-65% 

Head Start and Children with Asthma 31 OEI-09-01-00330 
Of the grantees that provide training and education on asthma 

to children with asthma, percent who teach them about what 

to do during an asthma emergency 

44% 32%-55% 

Of the grantees that provide training and education on asthma 

to children with asthma, percent who teach them about 

administering asthma medication 

33% 22%-44% 

Percent of grantees that provide education or training on 

asthma to children without asthma 37% 28%-46% 

Percent of grantees that provide education or training on 

asthma to parents of children with asthma 84% 77%-89% 

Of the grantees that provide education or training on asthma 

to parents of children with asthma, percent who teach them 

about recognizing symptoms of an asthma attack 

74% 66%-82% 

Percent of grantees that involve parent in the development of 

asthma management plans 65% 57%-73% 

Percent of records that have documentation of contact 

between parents of children with asthma and the program 

about the child’s condition 

39% 26%-52% 

Percent of grantees that provide education or training on 

asthma to Head Start staff 90% 86%-95% 

Of the grantees that provide education or training on asthma 

to Head Start staff, percent that teach them about recognizing 

symptoms of an asthma attack 

96% 93%-100% 

Of the grantees that provide education or training on asthma 

to Head Start staff, percent that teach them about what to do 

during an asthma emergency 

95% 91%-99% 

Of the grantees that provide education or training on asthma 

to Head Start staff, percent that teach them about how to 

administer asthma medication 

85% 79%-91% 

Percent of grantees that use the Head Start Bureau’s training 

guide, “Caring for Children with Chronic Conditions,” 

Module 3 

37% 29%-44% 

Percent of grantees that have not received assistance on 

asthma from the Head Start Training and Technical 

Assistance Network 

84% 79%-89% 

Percent of children who were identified as having asthma, but 

whose records contain no mention of the condition 13% 8%-17% 

Head Start and Children with Asthma 32 OEI-09-01-00330 
Percent of grantees that use a combination of parent 

reporting, physician diagnosis, and receiving asthma 

medication at school as the criteria for reporting children with 

asthma on the Program Information Report 

34% 26%-41% 

Percent of grantees that use physician diagnosis as the only 

criterion for reporting children with asthma on the Program 

Information Report 

30% 23%-37% 

Percent of grantees that use a combination of parent reporting 

and physician diagnosis as the criteria for reporting children 

with asthma on the Program Information Report 

19% 13%-26% 

Percent of grantees that use a combination of physician 

diagnosis and receiving asthma medication at school as the 

criteria for reporting children with asthma on the Program 

Information Report 

10% 6%-15% 

Percent of grantees that reported there is at least one other 

health condition they consider to be a health priority in addition 

to asthma 

65% 57%-72% 

Percent of grantees that reported that asthma is no more 

difficult to manage than any of the health conditions that 

children in their program have 

86% 81%-91% 

Percent of grantees that report that dental health is another 

health priority for their program 16% 10%-21% 

Percent of grantees that report that obesity is another health 

priority for their program 14% 9%-19% 

Percent of grantees that report that anemia is another health 

priority for their program 14% 8%-19% 

Percent of grantees that report that allergies are another 

health priority for their program 12% 7%-17% 

Percent of grantees that report that seizures are another 

health priority for their program 11% 7%-16% 

Percent of grantees that report that lead levels are another 

priority for their program 7% 3%-10% 

Note: In the tables above, point estimates and confidence intervals are rounded to the nearest percentage 

point. 

Head Start and Children with Asthma 33 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 General’s Public Affairs 

office at (202) 619-1343.