Academic performance in children with lupus

Lupus Foundation of America

Resource Content


Lupus is associated with decreased quality of life. One critical aspect of quality of life in children and adolescents with lupus is their academic performance. The factors that contribute to reduced academic performance in children with lupus remain poorly understood but have far-reaching implications.

What did the researchers hope to learn?

The researchers hoped to determine whether children with lupus have worse academic functioning relative to their peers of similar demographic and socioeconomic background. In addition, the researchers hoped to learn whether there were differences in these groups in terms of disease-related factors or cognitive, behavioral, and emotional functioning.

Who was studied?

Study participants included 40 children and adolescents with lupus, plus 40 same-sex, best friend controls (for purposes of comparison); they were recruited into the study at two U.S. pediatric rheumatology centers (Chicago, Illinois and Cincinnati, Ohio).

How was the study conducted?

For inclusion in the study, the lupus and control subjects had to be 9-18 years of age at enrollment. Children with lupus were excluded from the study if they had a history of conditions affecting cognitive functioning prior to the diagnosis of lupus, or if they had known structural brain abnormalities, neuropathies, or movement disorders.

Each child with lupus was asked to identify a friend, within one year of his/her age, of the same sex, and in the same school grade, for inclusion in the study for purposes of comparison (a control). Controls had to be healthy and free of structural brain abnormalities or known cognitive dysfunction.

All participants had to speak English as their first language. Informed consent was obtained from both parents and from all participants aged 12 years or older. Each participant underwent a physical exam and neurocognitive assessment. Lupus disease activity was determined for each child by with the Systemic Lupus Erythematosus Disease Activity Index 2k (SLEDAI-2K) and the British Isles Lupus Assessment Group Index (BILAG). Organ damage was assessed with the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI). The daily dose of prednisone (if any) was recorded as a measure of treatment intensity.

Neurocognitive testing was performed on each study participant with an age-appropriate battery of tests. The following were measured with appropriate psychometric instruments: behavioral and emotional functioning (anxiety, depression, self-regulation), intelligence, working memory, psychomotor speed, learning and recall of verbal and visual information, reading and decoding ability, arithmetic skills, and ability to sustain attention and inhibit impulsive responses. The following information was obtained by parental reporting: demographics (including ethnicity, maternal education, number of parents in the household, and family income), externalizing behavior (aggression, conduct problems), mental self-regulation (organization, planning, and self-initiation), executive functioning, and academic performance.

What did the researchers find?

The children with lupus were significantly older than their best friend controls. Otherwise, they were closely matched on other demographic indices. In both groups, 85% of participants were females, about half were African-American, about 30% were Caucasian, and less than 10% were Asian. For both groups, most of the participants were in high school and most of the mothers had been educated beyond high school.

The children with lupus had a disease duration of about two years and had mild-to-moderate disease activity and disease-related organ damage. About 78% of them were taking prednisone (daily dose of about 20 mg).

Parent-rated school performance was significantly lower in the children with lupus than in the healthy ones. However, the two groups did not differ significantly in terms of behavioral, emotional, cognitive, or executive functioning. In comparison to data available from the existing literature, the children with lupus studied here, however, were significantly impaired in terms of scores for working memory, processing speed, externalizing problems, and behavioral regulation.

Overall, academic competence was significantly related to disease activity (as indicated by both SLEDAI-2K) and organ damage (SDI), and also to higher prednisone dose.

What were the limitations of the study?

The researchers did not measure school absenteeism, information which could have have helped to explain the academic deficits observed in the children with lupus. Second, the number of children studied was relatively small, preventing firm conclusions about the differences observed between the children with lupus and their peers. Lastly, academic performance in this study was defined based on a single measurement (school competence ratings) from a single source (parents).

What do the results mean for you?

The results of this study indicate inferior academic performance in children with lupus, which associated with increased disease activity. However, there is no clear evidence that cognitive deficits mediate this relationship. Disruption of school attendance due to lupus and its treatments may significantly hinder successful academic functioning in these children. Therefore, management of lupus in children should consider the disruptive effect of illness and treatment on school attendance and performance.

In light of the current results, minimizing disruption of school attendance and participation should be one major goal of disease management in children with lupus. Also, the evaluation of neurocognitive functioning should be part of the routine care of children with lupus.

Academic outcomes in childhood-onset systemic lupus erythematosus 
Zelko F, Beebe D, Baker A, Nelson SM, Ali A, Cedeno A, Dina B, Klein-Gitelman MS, Ying J, and Brunner HI. (2012). 
Arthritis Care & Research (Hoboken) 64: 1167-1174.