Nigerian Journal of Paediatrics

C:\Users\Pelroxltd\Desktop\NJP website\2019\v46n2\1Asthma control and academic performance of school aged children with asthma.pdf

Niger J Paediatr 2019; 46 (2): 41 – 47

ORIGINAL

Nduagubam OC

CC – BY

Asthma control and academic

performance of school-aged

children with asthma

DOI:http://dx.doi.org/10.4314/njp.v46i2.1

Accepted: 7th May 2019

Abstract: Background: A number

class attendance register. Aca-

of factors are thought to influence

demic performance was assessed

Nduagubam OC (

)

the academic performance of chil-

using the average of the overall

Department of Paediatrics,

dren with asthma (Subjects) and

scores in the three term examina-

Enugu State University College of

asthma control is one. Reports on

tions of the academic session.

Medicine, (ESUCOM),

the influence/impact of asthma

Result: The prevalence of high

Enugu, Nigeria

control on the academic perform-

school absence among subjects

Email : obinopunchus@yahoo.com

ance of children with asthma are

with poor asthma control was

limited and the independent con-

higher compared to those with

tribution of asthma status, if any,

good asthma control and this dif-

to academic performance of chil-

ference was statistically significant

dren with asthma has been poorly

explored.

(

2 = 14.67; d.f = 1; p < 0.001).

Aims: To determine the influence

The difference between the median

of asthma control on the academic

(range) overall academic score of

performance of children with

children with poor asthma control

asthma in Enugu, Nigeria.

(79.96% (36.00% - 93.57%)) and

Methods: Children with Asthma

that of those with good control

(Subjects) aged 5 – 11 years were

(78.11% (37% - 99.57%)) was not

recruited consecutively at the

statistically significant ( U = 1235,

weekly asthma clinic of the Uni-

p = 0.486). However on multivari-

versity of Nigeria Teaching Hos-

ate analysis, good asthma control

pital (UNTH) Enugu, Nigeria.

had a significant positive effect on

Level of asthma control was as-

academic performance ( β = 1.080,

certained using the Childhood

p = 0.003).

Asthma Control Test (C-ACT)

Conclusion : Asthma control had a

tool. The IQ of the subjects was

significant positive effect on aca-

calculated using the validated

demic performance of school chil-

Ziler criteria and the table of

dren with asthma.

Draw

– A-person

Quotient

(DAPQ) by Ebigbo and Izuora

Keywords: Academic perform-

The total number of days of

ance, Asthma, Asthma control,

school absence for the academic

Children , Primary School

session was obtained from the

Introduction

children's academic performance as well as the exact

way in which poor asthma control may cause poor aca-

Asthma is one of the most common chronic illnesses

demic performance is not well documented. Increased

among children, affecting over six million children glob-

school absenteeism, impact of nocturnal asthma on these

ally. In Nigeria, studies in among children have re-

children and psychosocial impact of asthma are some of

the suggestions that have been put forward.

5-8

ported prevalence of 7.2 and 7.1 % in Ibadan and Enugu

respectively.

2,3

Children with asthma, similar to children

Asthma has been reported to be one of the most com-

with other chronic illnesses, are at the intersect of the

mon causes of school absenteeism among chronic health

health and education systems and are expected to com-

conditions in childhood and increased absenteeism by

pete with non-asthmatic counterparts in the same class-

school children with asthma has been well documented.

9-14

room under the same learning conditions. When asthma

Poorly controlled or persistent asthma could lead to a

is poorly controlled, children are said to be at greater

significant number of days of absence from school and

this can affect their academic performance.

5,6,15

risk for decrements in other areas of functioning which

Noctur-

may include their academic performance. Studies on the

nal asthma can affect children's sleep quality and dura-

effect of asthma status on academic performance are few

tion which can interfere with attention in school and

impact the quality of school work.

and to date, the extent to which asthma status affects

While Gonzales-Macias

reported a weak association

q = 1.0 – p = 0.5

between well-controlled asthma and good classroom

d = degree of accuracy at 95% confidence limit (0.05)

1.96 x 0.5 x 0.5

performance, Moonie et al noted that persistent asthma

n =

0.05

negatively affects academic performance. Although

384

Gonzales-Macias

used asthma control and Moonie et

and when study population is <10,000, nf = n

assessed asthma severity, their findings were simi-

1+ n

lar. However Nduagubam et al

in Nigeria reported

that there was no difference in the overall academic per-

where nf = final sample size

formance of children with asthma when compared to

n = sample size when study population is >10,000

children without. However while some studies

15, 16

sug-

N = study population size (number of school-aged asth-

gested that poor asthma status caused poor academic

matics attending the Asthma Clinic) = 148

performance through increase in school absence; Koinis-

nf = 384

Mitchell in a study in 2013 opined their poor academic

1 + 384

performance to poor sleep quality among children with

148

= 107

nocturnal or poorly controlled asthma.

More recently

Sample size allowing for 10% attrition = 120

still, another study by suggested that asthma may impact

The total number of children with a diagnosis of asthma

children's academic performance and attributed this im-

enrolled into the study was 120.

pact factors which include the increased school absence

and poor sleep quality observed in children with poor

Inclusion Criteria

asthma control.

Children aged 5-11 years, attending primary school

No studies to the best of my knowledge have been done

in Enugu metropolis.

Asthma diagnosed by a doctor.

19,20

on the relationship between asthma status (level of

asthma control) and academic performance among chil-

Attendance in the same school for at least one ses-

dren with asthma in Nigeria. This study therefore looked

sion before study enrolment.

at the effect of asthma control on the academic perform-

Attendance at the asthma clinic for at least

ance of primary school children with asthma in Enugu

12months.

State Nigeria.

Consent for the study given by care-giver.

Exclusion Criteria

Materials and Methods

Out of school children.

Study Design

Age less than five years or more than eleven years

of.

This was a cross-sectional, hospital- and school-based

Children with other chronic diseases like sickle cell

descriptive study.

disease, diabetes mellitus, tuberculosis, congenital

heart diseases or with history of neurologic illness

Study Area/Site

like seizure disorders and cerebral palsy. These

were excluded because the disorders are known to

The study was carried out at the University of Nigeria

affect academic performance, hence the independ-

ent effect of asthma may be difficult to determine.

Teaching Hospital (UNTH), Ituku/Ozalla, Enugu State.

The Subjects were children with asthma attending the

Children attending school outside Enugu metropolis

Paediatric Asthma clinic of the hospital. The clinic holds

Attendance of the present primary school for less

every Tuesday morning with four doctors and three

than one session before enrolment

nurses attending to an average of 25 persons, including

Refusal of consent by care-giver.

five new cases per week. The paediatric asthma clinic

Asthmatic children with incomplete data, since

from the hospital records attends to an average of 304

some of the information were obtained from the

patients per year, of which 148 patients (48.7%) are chil-

case notes.

dren aged 5-11 years.

Primary school-aged children with asthma attending the

Sample Size

weekly asthma clinic of the University of Nigeria

Teaching Hospital (UNTH), Enugu were the study

The minimum sample size for the study was determining

population. Consecutive children with asthma aged 5 – 11

using the formula for sample size calculation

years who have been in primary school for one academic

that when the study population is >10,000: n = z p q

session during the study period (September 2012 – Au-

gust 2013) were recruited. Before enrollment, in order to

ascertain eligibility, necessary data (including age, sex,

where n = sample size

school, class, medical history, occupation and education

z = z score at 95% confidence limit (1.96)

of both parents) were obtained from the accompanying

p = estimated prevalence when prevalence of

parent/caregiver of the asthmatic child and the child

poor academic performance in children with asthma is

subsequently assessed clinically for chronic and debili-

not known = 0.50

tating medical conditions such as heart disease, seizure

disorders and cerebral palsy that are known to affect

Oyedeji.

Class I represented the highest social class

academic performance independently.

One hundred

and class V the lowest. Each parent was scored sepa-

and twenty children with asthma who satisfied the inclu-

rately by finding the average score of the two factors

sion criteria were recruited after informed consent were

(occupation and educational level). The mean of the

obtained from their parents/caregivers. Criteria for in-

scores for the father and mother approximated to the

clusion in the study were children with asthma diagnosis

nearest whole number was chosen as the social class of

made by a doctor, aged 5 - 11 years attending primary

the child.

school within Enugu metropolis. The child selected must

have attended the same school for at least one academic

Health Research Ethics Committee of University of Ni-

session before enrolment and have been attending

geria Teaching Hospital (UNTH), Enugu approved the

asthma clinic of UNTH Ituku/Ozalla for at least 12

study and the Enugu State Ministry of Education gave

months.

clearance before the study was commenced. Information

obtained was recorded in a proforma. Means of aca-

At the clinic, children who met the inclusion criteria

demic performance and socio-economic class that were

were enrolled consecutively till the sample size was

not normally distributed were compared using the Mann

reached while those excluded were scheduled for con-

-Whitney U test. The significance of association be-

sultation. The level of asthma control was ascertained

tween categorical variables was determined using chi-

TM 22

using the Childhood Asthma Control Test (C-ACT

square. Correlation analysis was done using Pearson’s

This C-ACT

tool for children 4 to 11 years is made

correlation coefficient. Multiple linear regression analy-

up of seven questions with a total score of 27 as the

sis was used to assess for predictors of academic per-

highest score obtainable. Each child, as much as possi-

formance in children with asthma. The level of signifi-

ble, was allowed to answer the first four questions un-

cance was taken as p < 0.05.

aided while the care-giver answered the remaining three.

A score of 19 and below signifies poor control while

scores above 19 (20-27) indicate good control.

23,24

Results

There was no validated academic achievement measure

in Nigeria; hence this study, similar to earlier related

A total of 120 children with asthma were enrolled in the

studies,

25,26

employed the use of school examination

study. Eighty-one (67.5%) were males and 39 (32.5%)

report. At school, the average overall score in percent-

females (male: female ratio 2.1:1). The age range was 5

age for each child in each of the three term examinations

to 11 years while the mean age ± standard deviation

for 2012/2013 academic session was calculated as a

(SD) was 8.20 ± 1.92years. Seventy- five percent (75%)

measure of the overall score academic performance of

of the children in this study were from the higher socio-

the child. The average of the scores for the academic

economic classes I and II.

session for each of the children in each of the four key

Forty eight children with asthma (40%) had a history of

subjects (English, Mathematics, Social Studies and Sci-

hospital visits (emergency room visits/ hospital admis-

ences) expressed in percentage, was used as a measure

sion) which ranged from 1 to 5 days within the one year

of their specific academic performance. These repre-

period under consideration. Thirty-five percent of all the

sented the academic performances (Overall and specific)

subjects had acute asthma attacks as the only reason for

and were further graded as high ( ≥ 75%), average (50 –

hospital admission during the period. Majority (77.8%)

74%) and low (< 50%). Those with low scores were

of the asthmatics who had hospital admissions had an

considered as having poor academic performance. This

average hospital stay of one to three days before dis-

measure has been used previously for the assessment of

charge. High school absence was significantly associ-

academic performance of school children.

25,26,27,28

ated with hospital visits (

= 16.08; d.f = 1; p <

However, varying standards between individual teachers

0.001).

may affect this measurement approach.

All the children in this study had IQs within the normal

From the class attendance register, each child’s total

range for age and sex. The mean ± SD Draw A person

number of days of absence for the entire academic year

Quotient (DAPQ) scores for children with poor asthma

was obtained. School absence was classified as de-

control was 122.91±18.54 and children with good con-

scribed by Weitzman and colleagues. High school ab-

trol 123.41± 22.54. The difference was not statistically

sence was taken as >12 school day’s absence and low

significant ( p = 0.215).

school absence as 1 – 12 school days’ absence.

Thirty-three (91.7%) out of the 36 subjects with high

Each child was given a sheet of paper and pencil and left

school absence had poor asthma control while the re-

alone with as much time as they needed with the instruc-

maining 3 (8.3%) had good asthma control. The preva-

tion to draw a person.

30,31

The Intelligence Quotient (IQ)

lence of high school absence among subjects with poor

of the subjects and controls were calculated using the

asthma was higher compared to those with good asthma

validated Ziler criteria and the table of Draw-A- Per-

control and this difference was highly statistically sig-

son Quotient (DAPQ) by Ebigbo and Izuora.

nificant (Table 1).

Socio-economic status of both children with asthma and

those without was determined using the occupation and

educational attainment of their parents as proposed by

Table 1: Comparison of asthma control and school absence

Table 4: Age specific comparison of academic performance

amongst subjects

and asthma control of subjects

Asthma control

Poor

Good

Total

Age

Poor (n = 30)

Good (n = 90)

Mann-

P -value

No. of days absent n (%)

n (%)

(years)

Median

Median (Mean

Whitney U

(Mean rank)

rank)

Low absence

36 (54.5) 30 (45.5)

66 (100.0)

89.12 (15.00)

78.11 (6.75)

3.00

0.002

High absence

33 (91.7) 3 (8.3)

36 (100.0)

99.57 (2.00)

Total

69 (67.6) 33 (32.4)

102 (100.0)

82.28 (6.50)

92.84 (11.00)

18.00

0.089

X = 14.67; d.f = 1; p < 0.001

83.94 (12.42)

86.62 (16.27)

53.50

0.336

71.28 (7.17)

73.96 (14.28)

22.00

0.032

91.00 (2.00)

The median (range) overall academic score for children

49.39 (6.50)

68.31 (14.50)

18.00

0.015

with poor asthma control was 79.96% (36.00% -

93.57%) while that of those with good control was

NA = Not Available

78.11% (37% - 99.57%). The difference in the median

overall academic score for children with poor asthma

control and good control was not statistically significant

Discussion

( U = 1235, p = 0.486).

Out of the 120 children with asthma studied, 30 (25%)

In this study asthma control was found to be a predictor

had poor asthma control and academic performance of

of academic performance as children with good asthma

six of them (5%) was poor. There was no significant

control had better academic performance compared to

relationship between poor asthma control and academic

children with poor asthma control in the presence of

performance (Table 2).

other factors (age, socio-economic class, school absence

and IQ). The larger proportion of subjects with good

Table 2: Comparison of academic performance and asthma

asthma control compared to those with poor asthma con-

control of subjects

trol in this study may have influenced this result. Addi-

Academic Performance

tionally selection of the subjects for this study was from

Asthma control Poor

Average

Good

Total

the asthma clinic where these children were being fol-

n (%)

lowed up regularly and therefore the study population

Good

3 (3.3)

39 (43.3) 48 (53.3) 90 (100.0)

had more children with good asthma control. However,

Poor

3 (10.0) 9 (30.0)

18 (60.0) 30 (100.0)

Total

6 (5.0)

48 (40.0) 66 (55.0) 120 (100.0)

the effect of asthma control on academic performance

noted in this study is in alignment with some earlier

Gonzales-Macias

X = 3.18; d.f = 2; p = 0.204

studies.

15,16,17,18

Although

used

asthma control and Moonie et al

assessed asthma se-

However on the multiple regression, the coefficient of

verity, their findings were similar. Moreover, Koinis-

determination in the subjects (R = 0.311), indicate that

Mitchell et al in their study used both asthma severity

less than half the variation in academic performance is

and level of asthma control and their report suggested

explained by the model. Asthma control had a signifi-

that asthma control has significant impact on academic

cant positive effect on academic performance ( β =

performance of children with asthma

1.080, p = 0.003) but not school absence ( β = 0.148, p =

0.394) (Table 3).

Although increased school absence was suggested as the

route via which poor asthma control caused poor aca-

Table 3: Multiple linear regression result of predictors of aca-

demic performance among children with asthma;

15,16

the

demic performance among children with asthma

relationship between school absence and academic per-

Variables

p - value

formance in children with asthma is still being re-

searched.

9,10,11,15,16,18,33

Age

-3.776

<0.001

Children with persistent asthma

Socio-economic class

1.836

0.183

experience recurring episodes of absenteeism, which

DAPQ

0.034

0.579

may contribute to decreased school performance. Simi-

Asthma control

1.080

0.003

larly in this study, the prevalence of high school absence

No. of days absent

0.148

0.394

among subjects with poor asthma was significantly

R = 0.557; R = 0.311

higher compared to those with good asthma control. The

reason for increased school absence among the subjects

Children with poor asthma control had significantly

with poor asthma control compared to those with good

higher mean scores at 5years ( p = 0.002) and lower me-

asthma control is unknown but could probably be due to

dian overall academic scores at ages 9 ( P = 0.032) and

the frequent hospital visits by these children as was

11years ( p = 0.015). Comparisons could not be made at

found in this study which could take them out of school

6 and 10 years of age because none of the children at

more than those with good asthma control. However

these ages had poor control. There was a statistically

despite the increased school absence among asthmatics

significant negative correlation (Pearson’s) between age

with poor asthma control, it appeared not to affect their

and median overall score in subjects with poor (r = -

academic performance significantly when compared to

0.839, p <0.001) and good (r = - 0.341, p = 0.001)

those with good asthma control. The fewer number of

asthma control (Table 4).

children with poor asthma control compared to those

with good asthma control in this study may have masked

their effect. However on multivariate analysis, putting

probably due to their poor asthma control and may re-

other factors of age, Socio-Economic Status, number of

flect the challenges of school absence, poor sleep quality

days absent from school, DAPQ along with level of

faced by these children coupled with higher mental de-

asthma control, asthma control and age were found to

mands in advancing class at higher ages of 9 and 11

good predictor of academic performance. This is in

compared to 5 years. Further studies including studies

alignment with some earlier studies

15,16,18

. However the

on academic performance of children with asthma above

exact route via which asthma control affects academic

primary school age may offer more insight on this trend.

performance in these children was not further elucidated

in this study. Apart from increased school absence, some

earlier works have suggested that poor sleep quality in

and psychological impact

8,34

these children

of poor

Conclusion

asthma control as the possible route. Further studies on

the influence of asthma control on academic perform-

Children with good asthma control had better academic

ance are therefore needed.

performance compared to children with poor asthma

control.

The mean DAPQ scores for children with good asthma

control and that of children with poor asthma control in

this study were comparable. Similar reports on IQ have

Recommendation

been reported among children with asthma and those

with SCA.

25,34,35

This finding of similarity in mean

Good asthma control therefore is essential for a child

DAPQ of both children with poor asthma control and

with asthma to attain optimal academic potential. Par-

those with good asthma control probably means the in-

ents of children diagnosed with asthma should be en-

telligence of the children in both groups was comparable

couraged to attend asthma clinic run by specialists who

irrespective of the level of control of asthma hence

will ensure attainment and proper monitoring of their

asthma or its level of control may not directly affect

asthma control.

intelligence.

Regardless of the level of asthma control (good or poor);

Conflict of interest: None

age was observed to be a predictor of academic perform-

Funding: None

ance. This probably means age may influence academic

performance irrespective of the level of asthma control.

Similar trend of decline in IQ with increasing age was

Acknowledgement

also noted among the subjects. Such trend in decline in

IQ with age has been reported in children with other

My gratitude goes to the head teachers and teachers of

disease conditions such as Childhood diabetes , obe-

various schools visited for their co-operation. I also

sity and SCA . This probably buttresses the fact that

want to appreciate Professors Oguonu Tagbo and Ojin-

IQ is a major predictor of academic performance. How-

naka Ngozi as well as Late Dr Ibekwe Roland all of the

ever although the trend of decline in mean DAPQ was

University of Nigeria Teaching Hospital for their super-

observed in both groups (good and poor asthma control;

visory roles during the course of this study which I did

the decline appeared more obvious with increasing age

in partial fulfillment of the requirements for award of

among children with poor asthma control. However al-

fellowship of the National Post-graduate Medical Col-

though there was a decline in academic performance in

lege of Nigeria (NPMCN). I cannot fail to acknowledge

both groups; the trend in the decline in academic per-

the parents/caregivers for their contribution through

formance with increasing age among the children with

willingness to participate in the study as well as Mr.

poor asthma control appeared worse. The difference is

Uche Ikenna for assisting with data analysis.

References

1. Masoli M, Fabian D, Holt S,

3. Okoromah NC. A study of

5. Basch, C.E. Asthma and the

Beasly R. The global burden of

bronchial asthma among pri-

achievement gap among urban

asthma: Executive summary of

mary school children in Enugu

minority youth. J School

the GINA Dissemination Com-

urban area. Part 2 Fellowship

Health . 2011; 81: 606 – 613.

mittee report. Allergy. 2004;

Dissertation, National Post-

Reynolds, K.C., Boergers, J.,

59: 469-478.

graduate Medical College of

Kopel, S.J., and Koinis-

2. Falade AG, Olawuyi F, Osinusi

Nigeria 1995.

Mitchell, D. Multiple comor-

K, Onadeko BO. Prevalence

Bateman ED, Hurd SS, Barnes

bid conditions, sleep quality

and severity of symptoms of

PJ, Bousquet J, Drazen JM,

and duration, and academic

asthma, allergic rhino-

FitzGerald M, et al . Global

performance in urban children

conjunctivitis and atopic ec-

strategy for asthma manage-

with asthma. J Pediatr Psy-

zema in secondary school chil-

ment and prevention: GINA

chol . 2018; 43: 943 – 954.

dren in Ibadan, Nigeria. East

executive summary. Eur Respir

Afr Med J 1998; 75: 695-698.

J 2008; 31: 143-178.

7. Koinis-Mitchell, D., Kopel,

17. Koinis-Mitchell D. Asthma

26. Ibekwe RC, Ojinnaka NC,

S.J., Seifer, R. et al. Asthma-

symptoms impair sleep quality

Iloeje SO. Academic perform-

related lung function, sleep

and school performance in chil-

ance of school children with

quality, and sleep duration in

dren. Science Daily, Brown

epilepsy. J Coll Med 2008;

urban children. Sleep Health .

University. 2013.

13: 18-22.

2017; 3: 148 – 156.

18. Koinis-Mitchell D, Kopel SJ,

27. Akpan MU, Ojinnaka NC,

8. Swadi H. Psychiatric morbid-

Farrow ML, McQuaid EL, Nas-

Ekanem EE. Academic

ity in a community sample of

sau JH. Asthma and academic

performance of school

Arab children with asthma. J

performance in urban children.

children with behavioural

Trop Pediatr 2001; 47(2): 106-

2019.122 (5):471 – 477].

disorders in Uyo, Nigeria. Afr

19. Dolan CM, Frasher KE,

Health Sci 2010; 10: 154 –

Taras H, Potts – Datena W.

Bleecher ER. Design and

158.

Chronic health conditions and

baseline characteristics of the

28. Ogunfowora OB, Olanrewaju

students performance at school.

epidemiology and natural

DM, Akenzua GI. A compara-

J Sch Health .2005; 75: 255 –

history of asthma: outcomes

tive study of academic

266.

and treatment regimens

achievement of children with

10. Krenitsky- Korn S. High school

(TENOR) study. Ann allergy

sickle cell anemia. J Natl Med

students with asthma: attitudes

Immunol 2004; 92: 32-39.

Assoc 2005; 97: 405-408.

about school health, absentee-

20. Patel PH, Welsh C, Foggs MB.

29. Weitzman M, Klerman LV,

ism, and its impact on aca-

Improved asthma outcomes

Lamb G, Menary J, Alpert JJ.

demic achievement. Paediatr

using a coordinated care ap-

School absence: a problem for

Nurs.2011; 37:61-68.

proach in a large medical

the Paediatrician. Pediatrics

11. Gutstadt LB, Gillette JW,

group. Dis Manag 2004; 7: 102

1982; 69: 739-746.

Mrazek DA, Fukuhara JT, La

-111.

30. Ebigbo PO, Izuora GI. Draw a

Brecque JF, Strunk RC. Deter-

21. Perrin JM. Chronic illness in

Person Test – Standardization,

minants of school performance

Children In: Kliegman RM,

validation and guidelines for

in children with chronic

Arvin AM (Eds), Nelson’s text-

use in Nigeria. Enugu: Chuka

book of Paediatrics, 15 Ed.

asthma. Am J Dis Child 1989;

Printing Company Ltd. 1981;

143:471 – 475.

W.B Saunders Co 1996; 124-

7-32.

12. Bender BG. Are asthmatic chil-

127.

31. William TO, Fall A, Eaves

dren educationally handi-

22. Nathan RA, Sorkness CA, Kos-

RC, Woods-Groves S. The

capped? Sch Psychol

inki M, Schat M, Li JT, Marcus

reliability of scores for the

1995;Quart.10: 274-291.

P et al. Development of the

Draw-A-Person intellectual

13. Baxter SD, Rover JA, Hardin

asthma control test- A survey

ability test for children, ado-

JW, Guinn CH, Delvin CM.

for assessing asthma control. J

lescents and adults. J Psyco-

The relationship of school

Allergy Clin Immunol. 2004;

educ Assess. 2006; 24: 137-

absenteeism with BMI,

113: 59-65.

144.

academic achievement and

23. Rimington LD, Davies DH,

32. Oyedeji GA. Socio-economic

socio-economic status among

Lowe D, Person MG. Relation-

and cultural background of

fourth- grade children. J Sch

ship between anxiety, depres-

hospitalized children in Ilesha.

Health 2011; 81:417-423 .

sion and morbidity in adult

Nig J Paediatr 1985; 12: 111-

14. Nduagubam OC, Oguonu TA,

asthma patients. Thorax. 2001;

117.

Ojinnaka NC, Ibekwe RC. Im-

56: 266-271.

33. Silverstein MD, Mair JE,

pact of school absence on aca-

24. Schatz M, Sorkness CA, Li JT,

Katusic SK, Wollan PC,

demic performance of school

Marcus P, Murray JJ, Nathan

O'connell EJ, Yunginger JW.

children with asthma in Enugu,

RA, et al . Asthma Control Test

School attendance and school

Nigeria. J Exp esearch. 2017. 5

reliability, validity and respon-

performance: a population-

(2):1-7.

siveness in patients not previ-

based study of children with

15. Moonie S, Sterling DA, Figgs

ously followed by asthma spe-

asthma. J Pediatr.2001; 139:

LW, Castro M. The relation-

cialist. J Allergy Clin Immunol.

278-283.

ship between school absence,

2006; 117: 549-556.

34. Javad G, Ali A, Masume J. IQ

academic performance, and

25. Ezenwosu O.U, Emodi I.J,

scores of children with moder-

asthma status. J Sch Health

Ikefuna A.N, Chukwu B.F,

ate asthma: A comparison

2008; 78: 140-148 .

Osuorah C.O. Determinants of

with healthy children. Oman

academic performance in chil-

Med J. 2014; 29: 71-74.

16. Gonzales-Macias LD. Conse-

dren with sickle cell anemia.

quences of asthma in elemen-

BMC Paediatr. 2013, 13: 189-

tary students. ProQuest LLC ,

197.

Ph.D. Dissertation, Arizona

State University. 2009.

35. Daramola OO, Ayoola OO,

36. Lin A, Northam EA, Werther

37.

Belsky DW, CAspi A, Gold-

Ogunbiyi AO. The comparison

GA, Cameron FJ. Risk factors

man-Mellor S, Meier MH,

of intelligience quotient of

for decline in IQ in youth with

Ramrakha S, Poulton R,

atopic and non-atopic children

type I Diabetes Mellitus over

Moffitt TE. Is obesity associ-

in Ibadan Nigeria. Ind J Der-

the 12 years from diagnosis and

ated with a decline in intelli-

matol 2010; 55: 221-224.

illness onset. Diabetes Care.

gence quotient during the

2014:14:1385.

first half of the life course?

Am, J, Epidemiol.

2013;10:1093.