Managing asthma in the classroom.

Asthma is the most common chronic disease of childhood, affecting nearly 5 million children under the age of 18. Children with asthma account for 3 million hospital visits and 200,000 hospitalizations yearly. This adds up to an estimated $2 billion annually in health care costs (American Academy of Pediatrics, 1999). A child with asthma has three times the number of school absences as compared to the average non-asthmatic child. And the number of children affected has been growing. Since 1980, there has been a 160 percent increase in the disease in children under age 4 (Poirot, 1999). In an average classroom, one or two children are likely to have asthma (Majer & Joy, 1993).

Educators can take many steps to help their students manage asthma symptoms and cut down on the number of school days lost to this disease. An awareness of what triggers asthma and a few simple changes to the classroom could make a big difference for students with asthma. While asthma cannot be cured, it can be controlled to allow children to participate in typical school activities.

The Effect of Asthma on School Performance

Although the disease process of asthma has not been found to negatively affect academic performance (Bender, 1999; Gutstadt et al., 1989; Lindgren et al., 1992), other aspects of the illness do have an impact on a child's performance in school (Celano & Geller, 1993). The side effects of medications used to control asthma may interfere with a student's ability to concentrate, increase feelings of depression and anxiety, and interfere with short-term memory (Bender, 1995). Although the changes that result from these side effects are temporary and not a source of permanent neurocognitive impairment, the effect on the individual student may be consequential if educators are not aware of them.

Teachers should consider the possible psychosocial effects of asthma, in addition to the physical effects. These may include isolation from peers, fewer opportunities or less motivation for physical activity, and lowered expectations from sell educators, and family. By lowering their expectations for the asthmatic child, educators and parents deny that child the chance to realize his or her full potential. From math class to physical education, each child should be given the same opportunities, and teachers should adapt activities as needed. Adaptations can be as easy as providing time for a slow warm-up exercise before gym class to being aware of medication schedules and the effects of medication on the student before giving a test.

By being alert to the symptoms of asthma, side effects of medication, and ways to prevent asthma attacks, educators can help control for any negative effects on students. They can work with parents as a team to effectively manage the child's asthma. Many children remain relatively unaffected by asthma, especially when they have positive experiences at home and in school. Below are recommendations to assist teachers in working with students with asthma.

Tip #1: Know if any children in your classroom are diagnosed with asthma.

What Is Asthma?

Asthma is a chronic lung condition that produces episodes of breathing problems, such as coughing, wheezing, chest tightness, and shortness of breath. The wheezing is caused by a spasm of the bronchial tubes or by swelling of the mucous membrane. Although people at any age can suffer from asthma, it occurs most often in childhood or early adulthood. The recurrence and severity of an asthma attack is greatly influenced by secondary factors, such as mental or physical fatigue, exposures to allergens, and emotional situations. The severity and length of an asthma attack may vary and most children recover fully from an asthmatic episode, given the proper treatment. It is possible, however, for a continuous asthmatic state to last for hours or even days. In some people with severe asthma symptoms, repeated inflammation alters the airways and leads to permanent airway obstruction.

While the basic cause of asthma is unknown, there are known risk factors and effective ways to control or manage them. Genetics can play a role, as can viral infections and environmental exposures or triggers. Triggers are conditions, events, or allergens that contribute to an asthmatic episode or attack. Each child diagnosed with asthma has unique triggers.

Tip #2: Become aware of asthma triggers in your teaching environment.

Common Triggers of Asthmatic Episodes in the School Environment

According to the American Lung Association (2004) and the American Academy of Allergy, Asthma and Immunology (2004), the following are common triggers for asthma attacks:

* Viral upper respiratory infections 

* Exercise

* Stress and strong emotions

* Lung infections, such as bronchitis

* Changes in the weather

* Exposure to environmental irritants and allergens, including:

chalk dust 

dust mites

pets

fungi and mold

tobacco smoke

strong smells

wood smoke

chemical smells

cockroach droppings

pollen

perfumes

paint fumes 

In children over the age of 5, asthma is frequently associated with allergies. Seventy to 90 percent of children with asthma have allergies (Griffith, 1995). Educators and caregivers can reduce the risk for asthma attacks by controlling allergens in their teaching environments. Common triggers can be reduced or eliminated by diligently monitoring and maintaining the classroom environment. Dust, fungi, mold, and cockroach droppings can be kept to a minimum with proper cleaning. Educators can minimize strong smells in their room by eliminating the use of perfumes or chemical sprays. Although pets can be a nice addition to the classroom, they may trigger an asthmatic episode for some children and so should be carefully chosen and handled.

Tip #3: Know the early warning signs of an asthma attack.

Early Warning Signs of an Asthmatic Episode

Even diligence about keeping the classroom allergen free will not prevent all asthmatic episodes. You can do much to prevent the need for medical attention, however, by being aware of the early warning signs and taking appropriate actions in response. Younger children, or children with communication difficulties, may have difficulty identifying their symptoms. Educators dealing with infants and young children have an increased responsibility to notice early warning signs.

Parents usually can describe specific early warning signs of an asthmatic episode in their children. Everyone in contact with a child who suffers from asthma should be aware of such signs. Young children may present as restless or irritable prior to an asthmatic episode. The most common signs of an asthmatic episode include wheezing, difficulty breathing, persistent cough, chest tightness, sneezing, dark circles under the eyes, and clipped speech. Irritation of the nose and throat, thirst, and the need to urinate also are common antecedents to an asthma attack. The end of an attack is often marked by a cough that produces thick mucus (Frieman & Settel, 1994; Neuharth-Pritchett & Getch, 1999).

If any of the above signs are observed in an asthmatic child, the educator's first step should be to stay calm (modeling the call behavior for the child and classmates), and help the child relax in a quiet place. Asthma sets off a vicious emotional-physical cycle in children. Breathlessness and wheezing incites fear of suffocation. In turn, this anxiety produces further constrictions of the muscles in the airway, making breathing even more difficult (Frieman & Settel, 1994). Allow the child to sit and bend forward slightly with his eyes closed. Have the child put his hands on his stomach and pretend it is a balloon. As he inhales he should push his stomach out against his hands, blowing up the "balloon." When exhaling, he should feel his hands sink in toward his stomach, flattening the "balloon." This breathing technique will help relax the child and encourages deeper, oxygen-rich breathing. You may need to model this technique, as it is not natural for some children. It will be most effective if practiced before it is needed. In fact, the entire class can benefit from the calming effects of this breathing exercise.

Tip #4: Practice relaxation techniques.

The Role of Educators in Managing Asthma

Educators should consider themselves an important part of the asthma management process. Researchers have found that systematic and comprehensive education and collaboration among all involved--child, parents, educators, caregivers, and medical personnel--will increase the likelihood of successful asthma management (Wigal, Creer, Kotses, & Lewis, 1990). With successful asthma control, a child can expect an absence of symptoms or only minor asthma symptoms, no time lost from school, no significant limitations in physical activity, no emergency room visits, and little or no side effects from medication (Lenney, 1997).

Tip #5: Develop an asthma action plan.

Educators should have an asthma action plan that includes identification of the early warning signs of an asthma episode, information about current medications and the child's specific reactions to medication, and information about when to contact the physician or go to the emergency room. The asthma action plan should also include a description of the child's typical behavior. This is especially important for children who are unable to report their own symptoms. The specific steps to take if an asthmatic episode does occur should be clearly outlined. Collaboration with parents or caregivers is essential to a successful asthma action plan. Examples of comprehensive asthma care plans can be found in the literature (see, for example, Neuharth-Pritchett & Getch, 1999).

Every child's asthma management plan is different; therefore, teachers need to be aware of the individual child's asthma medications, medication side effects, and administration procedures. Check with your school administrator for the medication administration policy in your school.

Tip #6: Become familiar with resources for asthma education.

Many resources are available that can help teachers educate themselves and their students about asthma (Goldberg, 1994). Literature, teaching aides, and Web sites provide practical ideas for classroom implementation of asthma information.

Although asthma management in the classroom may seem a daunting task, educators can make the task easier by involving the whole class. While teachers and classmates can learn how to deal with an asthma episode, the most important person in the management of childhood asthma is the child. Children should be taught self-management of their asthma, which includes knowledge about their triggers, their medications, and their asthma action plans. Educators can help children control their disease and thus live their lives as unaffected by asthma as possible.

Resources

American Lung Association 1740 Broadway, 14th Floor New York, NY 10019-4374 212-315-8700 www.lungusa.org

National Heart, Lung and Blood Institute National Asthma Education Program P.O. Box 30105 Bethesda, MD 20814-4820 301-251-1222 (Ask for Managing Asthma in the School: A Guide for Schools)

Center for Children's Health Media P.O. Box 269 Wilmington, DE 19899 American Academy of Pediatrics www.aap.org 800-433-9016

Additional Web Sites

www.kidshealth.org Answers to frequently asked questions about asthma and allergies.

www.asthmabusters.com Kid-friendly asthma information sponsored by the American Lung Association.

References

American Academy of Allergy, Asthma and Immunology. (2004). Classroom triggers for asthma and allergies. Retrieved August 29, 2004, from www.aaaai.org/media/ news releases/2004/08/081604.stm

American Academy of Pediatrics. (1999). Guide for managing asthma in children. Elk Grove Village, IL: Author.

American Lung Association. (2004). What are asthma and allergy triggers? Retrieved August 29, 2004, from www.lungusa.org

Bender, B. G. (1995). Are asthmatic children educationally handicapped? School Psychology Quarterly, 1(4), 274-291.

Bender, B. G. (1999). Learning disorders associated with asthma. School Psychology Review, 28(2), 204-214.

Celano, M. P., & Geller, R.J. (1993). Learning, school performance, and childhood asthma: How much at risk? Journal of Learning Disability, 26(1), 23-32.

Frieman, B. B., & Settel, J. (1994). What the classroom teacher needs to know about children with chronic medical problems. Childhood Education, 70, 196-201.

Goldberg, E. (1994). Including children with chronic health conditions: Nebulizers in the classroom. Young Children, 49(2), 34-37.

Griffith, H. W., MD (1995). Complete guide to symptoms, illness and surgery. New York: The Putnam Group.

Gutstadt, L. B., Gillette, J. W., Mrazek, D. A., Fukuhar, J. T., LaBrecque, J. F., & Strunk, R. C. (1989). Determinants of school performance in children with chronic asthma. American Journal of Diseases of Children, 143, 471-475.

Lenney, W. (1997). The burden of pediatric asthma. Pediatric Pulmonol, 15, 13-16.

Lindgren, S., Lokshin, B., Stromquist, A., Weinberger, M., Nassif, E., McCubbin, M., & Frasher, R. (1992). Does asthma or treatment with theophylline limit children's academic performance? New England Journal of Medicine, 327, 926-930.

Majer, L. S., & Joy, J.H. (1993). A principal's guide to asthma. Principal, 73(2), 42-44.

Neuharth-Pritchett, S., & Getch, Y. Q. (1999). Children with asthma: Strategies for educators. Teaching Exceptional Children, 49(2), 34-37.

Poirot, C. (1999, Nov. 11). Doctors alarmed by skyrocketing cases of childhood asthma. The Buffalo News, pp. C1, C5.

Wigal, J. K., Creer, L. T., Kotses, H., & Lewis, P. (1990). A critique of 19 self-management programs for childhood asthma: Part L Development and evaluation of the programs. Pediatric Asthma, Allergy, and Immunology, 4, 17-39.

Ellen M. Hamm is Assistant Professor, Graduate Education and Leadership, Canisius College, Buffalo, New York.