Missed opportunities: Do states require screening of children for health conditions that interfere with learning?

Strong evidence supports the existence of Health Barriers to Learning (HBLs)—health conditions that when untreated or unmanaged can interfere with a child’s ability to learn and succeed in school. These HBLs include vision and hearing deficits, uncontrolled asthma, mental and behavioral problems, dental pain, persistent hunger, and the effects of lead exposure. However, 19% of US children aged 6 to 11 did not receive their annual checkup in the past year. School requirements for health screenings can help identify children with HBLs. This study explores which states require health screening for children in elementary school, and the extent to which the 7 HBLs are included. Methods Investigators reviewed websites of state departments of health and education, and legislation for all 50 states and DC. For states with mandated screenings and a required form, investigators applied structured analysis to assess HBL inclusion. Results No state mandated that schools require screening for all 7 HBLs. Less than half (49%) required comprehensive school health examinations and only 12 states plus DC required a specific form. Of these, 12 of the forms required documentation of vision screening, 11 of hearing screening, and 12 of dental screening. Ten forms asked about asthma and 9 required documentation of lead testing. Seven asked about general well-being, emotional problems, or mental health. None addressed hunger. When including states without comprehensive school health examination requirements, the most commonly required HBL screenings were for vision (80% of states; includes DC), hearing (75% of states; includes DC) and dental (24% of state; includes DC). Conclusion The lack of state mandated requirements for regular student health screening represents a missed opportunity to identify children with HBLs. Without state mandates, accompanying comprehensive forms, and protocols, children continue to be at risk of untreated health conditions that can undermine their success in school.


Methods
Investigators reviewed websites of state departments of health and education, and legislation for all 50 states and DC. For states with mandated screenings and a required form, investigators applied structured analysis to assess HBL inclusion.

Results
No state mandated that schools require screening for all 7 HBLs. Less than half (49%) required comprehensive school health examinations and only 12 states plus DC required a specific form. Of these, 12 of the forms required documentation of vision screening, 11 of hearing screening, and 12 of dental screening. Ten forms asked about asthma and 9 required documentation of lead testing. Seven asked about general well-being, emotional problems, or mental health. None addressed hunger. When including states without comprehensive school health examination requirements, the most commonly required HBL screenings were for vision (80% of states; includes DC), hearing (75% of states; includes DC) and dental (24% of state; includes DC). a1111111111 a1111111111 a1111111111 a1111111111 a1111111111

Introduction
The years that a child spends in primary school, typically pre-K or Kindergarten to 5th or 6th grade and spanning ages 4 through 12, are critical in his or her health, psychological, social, and educational development [1,2]. All of these domains are interdependent and fundamental building blocks of future quality of life and social and financial stability [3,4].

Health Barriers to Learning
Extensive research exists linking health and a child's ability to perform optimally in school [5,6]. For children in primary school, specific conditions with a strong evidence base, referred to here as "Health Barriers to Learning" (HBLs), include: vision and hearing deficits, uncontrolled asthma, mental and behavioral problems, dental pain, persistent hunger, and the effects of lead exposure. Left untreated, these HBLs can adversely affect a child's ability to receive and process information, pay attention in class, ability and motivation to learn, attendance, academic performance, and even his or her chances of graduating from high school [7]. The evidence base for these specific health barriers is described in detail in the 2017 literature review, Health Barriers to Learning: The Prevalence and Educational Consequences in Disadvantaged Children [7], but are summarized below.

Vision
Though estimates of prevalence vary depending on population and specific vision issues, studies show that 22%-30% of children fail vision screening [8][9][10][11]. About 80% of learning occurs through visual tasks such as reading, writing and using computers; studies conclude that uncorrected vision problems impede a child's ability to read and that correction of the problem improved performance [12][13][14].
Hearing About 1% of children entering school are estimated to have hearing loss [15]. However, concerns are increasing about noise-induced damage, and studies have shown higher rates of hearing loss in adolescence, especially when high frequencies are added to screening tests [16]. Even minimal uncorrected hearing loss is associated with increased risk of poor performance on educational tests; higher rates of dysfunction in speech, language, and behavior; and higher rates of social emotional difficulties, including lower self-esteem [17-19].

Asthma
While asthma affects about 9% of school-age children nationally, rates as high as 30% have been shown in high-risk minority groups and high-poverty neighborhoods [20]. Poorly controlled asthma has been shown to negatively affect school performance through decreased school readiness, increased absences, and sleep deprivation [21][22][23]. Poorly controlled asthmatics have been shown to miss 18 days of school per year due to asthma, compared to 2 days per year for students whose asthma is well controlled [24,25].

Mental and behavioral health
In national survey data from 2015, the percentage of children with serious emotional or behavioral difficulties among children ages 4-7 was approximately 4%, compared with children ages 8-10 at 6%, and children ages 11-14 at 8% [26]. Similar surveys have shown that an additional 17% of children ages six to 11 had minor emotional or behavioral difficulties [27]. Particularly strong evidence exists for the negative impact of attention problems on both math and reading scores, and on school dropout [28-30].

Dental pain
About 37% of children aged 6 to 9 have dental caries, but the number almost doubles, to 69%, for children living in poverty. Approximately 14% of children overall have caries that are untreated, but the numbers exceed 30% in high-risk minority populations [31]. About 4%-7% of students miss school due to dental problems [32,33]. Multiple studies found that children with dental pain are significantly more likely to sleep poorly, miss school, and are less likely to complete all of their required homework [32,34,35]. Several studies have associated dental pain with lower grades [32,34].

Persistent hunger
According to national survey data, among households with children, about 17% of households experienced food insecurity during the prior year [36]. Chronic hunger in children has been associated with delayed development, higher rates of both internalizing and externalizing mental health problems, and decreased classroom participation [37][38][39]. Some studies have shown an association with lower math scores and increased need to repeat grades [40,41].

Effects of lead exposure
Lead exposure primarily affects children under 7 years old, but the effects are significant, and thus extremely relevant to screening in the early years of school entry and attendance. Nationally, about 2.6% of children younger than 7 have elevated blood lead levels, but in high poverty populations living in high-risk areas, studies have shown histories of elevated lead levels in as many as 69% of children studied [42,43]. The term 'elevated blood lead levels' refers to the reference value of 5 μg/dL, though research shows that even lower levels can impact cognition and the developing brain [44]. Numerous studies show decreases in IQ, school performance, and reading and math scores as blood lead levels increase in young children [45][46][47][48].
Evidence exists that other health and psychosocial conditions impact educational outcomes, most frequently in the content areas of poverty, trauma, adverse childhood experiences, and sleep [49][50][51][52][53]. Because they are often interrelated with the aforementioned conditions, they warrant mention and are included in the discussion, but not included as specific elements in this study. For any child, a specific chronic health condition that impacts cognition, functioning, or attendance can impact their school performance, and is important to be identified and managed. To be most broadly applicable, this study is limited to the elements listed above, which are both common and supported by strong evidence to impact educational outcomes.

Gaps in health screening for children
Pediatric primary care recommendations for school-age children include an annual well child check with a full history, physical examination, anticipatory guidance (age-appropriate health education to promote wellness and prevent disease and injury), and targeted screenings [54]. Each year, the American Academy of Pediatrics publishes updated, evidence-based/informed recommendations on specific screenings to be performed for children of each age. According to these guidelines, an age-appropriate behavioral health/mental health assessment, a brief screen for hunger [55] and food insecurity, and a physical examination that includes dental are recommended for every annual well child check. Vision screening is recommended at 6 of the 9 annual visits between the ages of 4 and 12; hearing screening is recommended 5 times in this same interval, both with condition-specific risk assessments to be performed at the annual visits in between. Lead screening is recommended earlier in childhood, at ages 1 and 2, but annual risk assessments should be done until age 6, and all children should have had at least one blood test by age 4 [54,56]. There are not widely adopted guidelines for asthma screening in general pediatric populations, but the standard of care is for an annual well child check that includes questions about cough and breathing trouble that, if affirmative, should lead to a more extensive assessment for asthma [57]. For the above schedules, there are additional recommendations for more frequent screening for children living in poverty, those with specific risk factors, and for children who were not fully screened in prior years [56,58,59]. Whereas children do not necessarily need to be screened for all of the HBLs every year, they should be seen and assessed each year to determine which screenings they do need.
If all children received annual well child checks, and all health care providers followed the best-practice guidelines, children would be regularly screened for the Health Barriers to Learning through general primary care. However, nationwide 20% of school-aged children-9.8 million children aged 6 to 17-did not receive their well child checks in the past year. Rates of missed well child checks are high among 6 to 11 year olds (19%), children from families below the poverty line (19%), Hispanic children (21%), and uninsured children (44%) [60].

Role of schools in facilitating screening.
A key strategy to support timely identification and treatment of educationally relevant health conditions in school-aged children is through health screening requirements for school admission, attendance, and activity participation [61]. This can be achieved by school-required health forms completed by the child's usual doctor or community healthcare provider, through screenings at offered at school, or through other types of community partnerships.
Role of states in ensuring screening gaps are minimized. There is no federally required school health screening form or set of school health screening requirements. States are able to create standard forms or screening requirements for schools, but are not required to do so [62][63][64]. There appears to be little consistency around health screening or particular requirements targeting Health Barriers to Learning. This represents a potential gap in the health safety net for children that is also relevant to their performance and at school [65,66].

Study scope and objectives
In review of the literature, no comprehensive assessments of state level health screening requirements for primary school students were identified that were not restricted to a single health condition [67]. This study's objectives are to fill that information gap in the following ways: 1) assess the extent to which states mandate schools to require-through school-based or community-delivered services-health screening for children age 4-12, and 2) assess the extent to which the evidence-based HBLs listed above are included when screening is required. This information has the potential to influence policy around requirements for student health screenings, and to provide a base for future studies on cost effectiveness, implementation, and consideration of health conditions to be included in screening requirements.

Methods
For each state, investigators asked: Does the state mandate that schools require screening of children for all seven of the Health Barriers to Learning: vision and hearing deficits, uncontrolled asthma, mental and behavioral problems, dental pain, persistent hunger, and the effects of lead exposure?
To assess the degree to which this was accomplished, investigators asked: 1. Does the state mandate comprehensive school health examinations?
a. If a school health examination is required, is it required at school entry only or more frequently?
b. If school health examination is required by legislation, is there a specific form that is required?
c. If a specific form is required, to what extent does the form include the 7 Health Barriers to Learning?
2. Does the state mandate schools to require students to be screened for vision, hearing and/ or dental problems for school entry or more frequently? What is the required frequency?

Comprehensive school health examinations
For information on requirements for comprehensive school health examinations, investigators reviewed state department of health and state department of education websites and also websites on state legislation for all 50 states and the District of Columbia (DC). For states where mandates for comprehensive school health examinations could not be found through any of these sources, attempts were made to contact both the departments of health and education via email and phone. In cases where none of these steps led to definitive identification of legislation or requirement for a form, investigators have noted that the information was not identified, versus a definitive conclusion that either or both do not exist.

School health form content
For states that required a comprehensive school health examination and a specific school health form, investigators applied structured content analysis to the forms to assess inclusion of each HBL. Investigators identified key variables and assigned categorical values to cover the range of possible responses. For the purposes of this study, asthma was considered to be included on a form even if not specifying control status. Mental and behavioral problems were considered to be included if the form asked about general mental or behavioral health, specific mental health or behavioral conditions, or general well-being. Dental pain was included if the form required a dental exam or asked about dental problems. Persistent hunger was included if the form mentioned hunger or food insecurity. Two investigators each coded all forms to determine inter-rater reliability. Any differing responses were discussed and resolved by consensus. Cohen's Kappa yielded a score of 0.962 and there was 97.6% agreement. Responses were then analyzed using SPSS version 23 to determine descriptive frequencies. It should be noted that the high level of agreement most likely was influenced by the fact that both coders, though working independently, had worked with the research team to create the instrument, which increased familiarity. In addition, the coding was not subjective, it was a simple yes or no as to whether or not the information appeared on the form.
State-mandated screening requirements for vision, hearing and dental problems. Investigators conducted a preliminary review of the school requirements for screening of health conditions listed in the State School Health Policy Database compiled by the National Association of State Boards of Education. Among the Health Barriers to Learning, state mandates for screening vision, hearing and dental problems were the most common. Most states' requirements for the screening or assessment of the other Health Barriers to Learning (uncontrolled asthma, effects of lead exposure, and mental health and behavioral problems and persistent hunger) were most often addressed through the comprehensive health examinations, if at all [64]. The research team focused on further investigating statewide screening requirements for vision, hearing, and dental problems through a thorough review of reports and websites compiling health-screening requirements by state [68][69][70].
The study was not submitted for review, as the Institutional Review Board at William Paterson University does not review studies that do not involve human subjects.

Results
Information was obtained for 50 states and DC (see S1 Appendix for detailed state by state findings).

Requirements for comprehensive health examinations
Only DC was found to require an annual comprehensive health examination for school. Other than DC, 24 states have legislation requiring comprehensive health examinations at school entry. Some were required more frequently, but not annually. For 26 states (51%), mandates for comprehensive school health examinations could not be identified (Table 1).

Requirements for school forms
For 12 states and DC, investigators identified language on the state website or in state legislation explicitly stating that a particular form or a form that is equivalent in content is required. For the remaining 12 states, the form is either optional or it is not clear whether the form or its contents are required or optional (Table 1).

Required forms: Health Barriers to Learning
The 13 forms that were clearly required, 12 states (24% plus DC) were assessed for content. None included all 7 Health Barriers to Learning (Table 2). Twelve forms required documentation of vision screening, and 11 required documentation of hearing screening. Forms from 12 states required a dental screening (by a primary care or dental provider), and 9 asked about lead exposure. Ten forms asked if the student had diagnosed asthma but only four asked about general breathing issues, coughing, or wheezing. Nine of the forms asked about behavioral issues, and seven asked about general well-being, emotional problems, or general mental health. None of the forms inquired about or assessed risk for hunger.
State mandated school screening requirements for vision, hearing, and dental problems. Screening can be offered directly at the schools, or by requiring parents to obtain screenings from a child's healthcare provider. Investigators identified 42 states (including DC, 82%) with vision screening requirements, and 38 states (including DC, 75%) with hearing screening requirements. Required frequency of screening varied by state, with only 4 states (including DC, 8%) identified with annual vision screening requirements and only DC with annual hearing screening. Dental screening requirements were less common, with requirements identified in only 12 states (including DC, 24%). See S1 Dataset for greater detail.

Discussion
This study identified no state mandated assessment of all 7 Health Barriers to Learning for school records or participation. Annual comprehensive health screening requirements for school were only identified for DC. As presented in the results above, though most states (80%) do have student vision screening requirements and about 3/4 (75%) require hearing screening at least once, less than half (49%) require a comprehensive health examination.
Screening for HBLs is only one element of ensuring good health to optimize each child's well being and experience in school. Ideally, all children should get their annual well child check as part of ongoing care from a medical home-a usual source of comprehensive, coordinated, high quality of care in their community. This should include developmental screening, sleep and trauma history, discussion of absences due to illness, assessment of school readiness, and identification and management of any disabilities or chronic illnesses that will require support in school. However, as mentioned in the introduction, 19% of children aged 6 to 11 did not receive their annual checkup in the past year, with higher rates for children in certain subpopulations, such as those who are uninsured (up to 44%) [60]. A school requirement for a health screening and physical examination form is one way to help ensure that families do go to community clinics to receive this care. The presence of specific elements on the form can guide clinicians to implement best-practice, age-appropriate screening protocols for each of  the HBLs, ensure inclusion of elements most important to school performance in their examination, and facilitate communication of relevant findings to the school. Requirements for student health screening forms that include a comprehensive health examination have the added benefit of increasing the likelihood that children will receive other important health care, health education, and anticipatory guidance. Requirements for an annual review of age-appropriate screenings could help to ensure that health problems that develop and change over time are consistently identified and managed. Access to community-based care remains challenging for many families for reasons of cost, transportation, inability to take off work, and competing priorities [71]. Partnerships with local health care providers and school-based screenings and services can help to ensure that children with these barriers are still appropriately screened and managed [72,73]. From a public health and cost standpoint, there are obviously limitations to what a school or school system can do in terms of direct screening and follow-up, but investment in this capacity may have potential for return on investment through reduced absenteeism, reduced grade-repetition, improved reading and math scores, and increased graduation rates. Legislation and appropriate funding will both be necessary for schools to be able to effectively offer such services for the students that need them. This will be especially important to schools and communities with large percentages of children living in poverty, as typically they will have the highest need, poorest healthcare access, and the least resources.

Study limitations and need for further research
Information on requirements of each state was limited to what was publicly available and discoverable through the search methodology of the study. Additionally, this study focuses on state mandates and does not capture local-level requirements. Finally, it is important to note that existence of state mandates and specific forms does not equal compliance. Further research is recommended to explore compliance, and also to explore the extent to which school systems require and track resolution of health problems identified through screenings. Further cost-effectiveness, return on investment, and implementation strategies research would also facilitate evidence-based recommendations around screening, in particular for those offered directly in school. Further study of systems with successful implementation of annual student health screening requirements, like DC, could help to develop implementation and sustainability strategies.

Conclusions
The lack of state requirements for annual health screening of students in elementary schools represents a missed opportunity to identify children who are burdened with HBLs. Without state mandates and accompanying comprehensive forms and protocols, children continue to be at risk of untreated health conditions that undermine their success in school.
Supporting information S1 Appendix. State-by-state requirements for school screenings in grades Pre-K to 6. (DOCX) S1 Dataset. Data for state-level school health screening requirements grades Pre-K to 6.