Childhood Rheumatic Disease Negatively Impacts Standardized Test Scores

Limited physical function, fatigue, mental health issues (resulting from chronic disease), and medication issues can further affect the ability of children with rheumatic disease from performing well in school.

Patients with childhood-onset chronic rheumatic diseases (ChildCRD) were shown to perform worse than peers in a control group on grade 12 standardized testing, regardless of sociodemographic and mental health comorbidities, according to a study published in Journal of Rheumatology.1

“Although most affected children will now reach adulthood, they will continue to experience disease activity and accrue morbidities. ChildCRDs directly affect children’s physical function, limiting their abilities to participate fully or effectively in school,” investigators stated. “Fatigue, mental health issues (as a result of ChildCRD, maladaptation, or preexisting), and adverse effects of medications can further affect the ability of children with ChildCRD to perform optimally in school.”

Within this retrospective, population-based cohort study, information on healthcare use and education outcomes for patients with ChildCRD, focusing on juvenile arthritis (JA) and systemic autoimmune rheumatic diseases (SARD) specifically, was obtained from the Manitoba Population Research Data Repository (PRDR) at the Manitoba Centre for Health Policy (MCHP) from January 1979 and December 1998. Childhood-onset was defined as receiving a diagnosis of disease prior to 17 years of age.

Primary outcomes evaluated the grade 12 Language Arts Achievement Index (LAI) and the Math Achievement Index (MAI) scores. Both indexes utilized standardized test results, graduation information, grade repetition, and withdrawal.

Additionally, sociodemographic, mental health factors, and a ChildCRD diagnosis were tested for scores using a multivariable linear regression. Mental health morbidity included attention deficit hyperactivity disorder, conduct disorder, substance use disorder, mood and anxiety disorders, and psychotic disorders. Three time periods were subdivided into premorbid, intercurrent, and disease course.

A total of 541 patients diagnosed with ChildCRD were matched by age (± 1 year), sex, and postal codes with 2713 controls. Controls were required to have continuous health insurance from birth through 21 years.

Patients with ChildCRD were more likely to fail or did not take either language arts (51% vs 41%) or math (61% vs 55%) tests when compared with controls. Overall lower unadjusted LAI scores (–0.22, P < 0.0001) and MAI scores (–0.21, P < 0.0001) were reported in the ChildCRD group. Unadjusted analysis showed patients with ChildCRD had lower LAI and MAI scores by about one-fifth of an SD.

Based upon multivariable analysis, ChildCRD diagnosis, family income assistance, child welfare services, lower socioeconomic status, mental health morbidities, and a younger maternal age at first childbirth were associated with lower LAI and MAI scores. When adjusting for other covariates, ChildCRD was a significant predictor of enrollment in grade 12 by 17 years of age.

Limitations included not being able to analyze ethnocultural factors and parental education information. While investigators were not able to obtain individual-level measures of socioeconomic status, the sociodemographic and mental health factors obtained within this repository were deemed the most comprehensive to date.

“Pediatric rheumatologists or other healthcare providers should perform a more holistic assessment of each patient with ChildCRD for additional risk factors that could adversely affect their academic performance and elicit information about perceived barriers to the patient’s school experience,” investigators concluded. “If additional risk factors are identified or the patient or family expressed difficulties in their schoolwork, the pediatric rheumatologist should engage with student services personnel within the school or school district to advocate for additional assessments and/or supports for each patient.”


Lim LSH, Ekuma O, Marrie RA, et al. A Population-based Study of Grade 12 Academic Performance in Adolescents With Childhood-onset Chronic Rheumatic Diseases. J Rheumatol. 2022;49(3):299-306. doi:10.3899/jrheum.201514