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Do Health and Education Agencies in the United States Share Responsibility for Academic Achievement and Health? A Review of 25 Years of Evidence About the Relationship of Adolescents' Academic Achievement and Health Behaviors

Open AccessPublished:March 26, 2013DOI:https://doi.org/10.1016/j.jadohealth.2013.01.008

      Abstract

      Purpose

      The United States Centers for Disease Control and Prevention monitors health-risk behaviors of adolescents in United States, which include (1) violence; (2) tobacco use; (3) alcohol and other drug use; (4) sexual behaviors contributing to unintended pregnancy and sexually transmitted diseases; (5) inadequate physical activity; and (6) unhealthy dietary behaviors. We reviewed original research published in peer-reviewed journals between 1985 and 2010 to synthesize evidence about the association of adolescent health-risk behaviors and academic achievement.

      Methods

      Using predetermined selection criteria, 122 articles were included that used at least one variable for health-risk behaviors and also for academic achievement.

      Results

      For all six health-risk behaviors, 96.6% of the studies reported statistically significant inverse relationships between health-risk behaviors and academic achievement.

      Conclusions

      With this persuasive evidence about the interrelationship of health-risk behaviors and academic achievement, it is imperative that leaders in education and health act together to make wise investments in our nation's school-age youth that will benefit the entire population. A unified system that addresses both health behavior and academic achievement would have reciprocal and synergistic effects on the health and academic achievement not only of children and adolescents, but also of adults in the United States.

      Keywords

      Implications and Contribution
      Among adolescents, health-risk behaviors are inversely related to academic achievement. While this inverse relationship is not new information, the reported strength of the interrelationship is compelling and suggests that a unified system that addresses both health behavior and academic achievement would have reciprocal and synergistic effects.
      Historically, the United States (U.S.) has turned its focus to the health of students in response to crises, such as inadequate nutrition, outbreaks of communicable diseases (e.g., polio in the 1950s), drug abuse, teen pregnancy, sexually transmitted infections, and unmet mental health needs. In 1988, with cases of acquired immunodeficiency syndrome emerging in the U.S. population, the Centers for Disease Control (now the U.S. Centers for Disease Control and Prevention [CDC]) focused on the potential of schools in the nation to prevent the spread of human immunodeficiency virus (HIV) infection.
      From surveillance conducted by CDC, six health-risk behaviors of adolescents emerged that contribute to the leading causes of death, disability, and social problems among youth and adults in the U.S. [
      • U.S. Centers for Disease Control and Prevention
      Youth risk behavior surveillance—United States.
      ]: tobacco use, alcohol and other drug use, sexual behaviors that contribute to unintended pregnancy and sexually transmitted diseases (STDs) (including HIV infection), behaviors that contribute to unintentional injury and violence, unhealthy dietary behaviors, and physical inactivity. The CDC created a national surveillance system, the Youth Risk Behavior Surveillance System, to collect data about health-risk behaviors of school-age youth [
      • Kolbe L.J.
      An epidemiological surveillance system to monitor the prevalence of youth behaviors that most affect health.
      ].
      The purpose of this study was to determine the extent, if any, to which there is published evidence of statistically significant relationships among the six identified health-risk behaviors and academic achievement of school-age youth in the U.S.

      Review of Literature

      For decades, researchers have suggested that efforts designed to promote academic success among youth may also reduce the students' health-risk behaviors [
      • Hawkins J.D.
      Academic performance and school success: Sources and consequences.
      ]. In 1990, in a report titled Code Blue, the National Commission on the Role of the School and the Community in Improving Adolescent Health stated, “Efforts to improve school performance that ignore health are ill-conceived, as are health improvement efforts that ignore education” (p. 9) [
      • Code Blue
      National Commission on the Role of the School and the Community in Improving Adolescent Health.
      ]. In 1992, the relationship between substance use and low academic performance was described in the literature as “mutually reinforcing” [
      • Allison K.R.
      Academic stream and tobacco, alcohol, and cannabis use among Ontario high school students.
      ]. In 1997, a task force convened by the Institute of Medicine of the National Academy of Sciences concluded, “Schooling is the only universal entitlement for children in the United States. The committee believes that students, as a part of this entitlement, should receive the health-related programs and services necessary for them to derive maximum benefit from their education and to enable them to become healthy, productive adults” (p. 14) [
      ].
      Although other reviews have been published about the relationship of health and academic achievement, none have included all six health-risk behaviors. In 2005, Taras published a two-part review of research about the relationship of two health-risk behaviors—physical inactivity and unhealthy dietary behaviors—and academic achievement [
      • Taras H.
      Nutrition and student performance at school.
      ,
      • Taras H.
      Physical activity and student performance at school.
      ]. In 2007, a review of primary research by Murray and colleagues [
      • Murray N.G.
      • Low B.J.
      • Hollis C.
      • et al.
      Coordinated school health programs and academic achievement: A systematic review of the literature.
      ] focused on specific school health interventions and their effects on academic achievement; the interventions targeted some but not all of the six health-risk behaviors.

      Methods

      We conducted scientific literature searches through PubMed, ERIC, and Ovid (PsychInfo), using MeSH subject headings and related thesaurus index terms (Table 1). Only publications meeting the following criteria were included for review: (1) study subjects were school-aged children (6–18 years) in the U.S. or Canada enrolled in school; (2) the article was published between 1985 and before 2011 (a 25-year span) in a peer-reviewed journal; (3) research included at least one of the following educational outcomes: grade point average (GPA), academic grades in specific subjects, performance on standardized tests (in a variety of subjects such as math, reading, etc.), years of schooling completed, high school graduation or passing the General Educational Development Test, and grade-level retention; (4) the sample size was at least 100 students; (5) relationships were reported to be statistically significant, whether positive or inverse, or reported as insignificant; and (6) meta-analyses were excluded.
      Table 1Publication selection criteria and search terms
      Publication selection criteria
      1. Article was published in a peer-reviewed journal between 1985 and before 2011 (25-year span)
      2. Study subjects were school-aged children (6–18 years) in the United States or Canada.
      3. Research included at least one of the following educational outcomes:
       a. Grade point average
       b. Academic grades in specific subjects
       c. Performance on standardized tests (in a variety of subjects such as math, reading, etc.)
       d. Years of schooling completed
       e. Grade-level retention.
      4. The sample size was at least 100 students.
      An exception was made to the sample size criterion; one study of nutrition and dietary behaviors had a sample of 97 and not 100, a 3% variation.
      5. The publication reported results of statistical analysis of the relationship of one or more of the health-related behaviors and one or more of the variables used for educational outcomes. Publications were included when the relationships were reported to statistically significant (whether positive or inverse) or reported as insignificant.
      6. Meta analyses were excluded
      Primary Search TermsSecondary Search TermsTertiary Search Terms
      1. Academic achievementAcademic achievement
      Academic problems
      Educational status
      Education measurement
      2. Health-risk behaviorsRisk-taking
      Adolescent behavior
      Health behavior
      Health status
      3. Tobacco useSmoking
      Tobacco use disorder
      Tobacco, smokeless
      4. Substance useAlcohol UseAlcohol drinking
      Alcoholic intoxication
      Marijuana UseMarijuana abuse
      Marijuana smoking
      Substance UseCrack cocaine
      Heroin dependence
      Cocaine-related disorders
      Substance abuse, intravenous
      Designer drugs
      Substance-related disorders
      5. Sexual behaviorsSexual BehaviorsSexual partners
      Sexual behavior
      PregnancyPregnancy in adolescents
      Unsafe sex
      Contraception UseSafe sex
      Contraception
      Contraception, barrier
      Ovulation inhibition
      Contraception behavior
      Condoms
      Condoms, female
      6. ViolenceUnintentional InjuriesSeat belts
      Head protective devices
      Bicycling
      Automobile driving
      Victimization/HarassmentSafety
      Crime victims
      Wounds, stab
      Wounds, gunshot
      Wounds and injuries
      Violence PerpetrationCrime
      Social problems
      Dangerous behavior
      Violence
      Weapon Carrying and TheftFirearms
      Theft
      Dating ViolenceRape
      Sex offenses
      Suicide Ideation/AttemptsSuicide
      Suicide, attempted
      7. Physical activityExercise/Physical ActivityExercise
      Physical Education
      Physical Fitness
      Fitness Centers
      Sedentary ActivityInternet
      Television
      Videogames
      8. NutritionDietary BehaviorsBulimia
      Weight loss
      Body weight changes
      Fasting
      Eating disorders
      NutritionDiet
      Child nutrition
      Adolescent nutrition
      Food habits
      Food preferences
      Child nutrition disorders
      Milk
      Fruit
      Vegetables
      Food service
      Nutrition policy
      a An exception was made to the sample size criterion; one study of nutrition and dietary behaviors had a sample of 97 and not 100, a 3% variation.
      After applying the criteria, there were not enough studies available about the relationship of academic achievement with unintentional injuries or suicide to include them with other violence-related risk behaviors. We included a total of 122 publications in peer-reviewed journals in this review; 26 studies addressed more than one health-risk behavior and the applicable results appear in the summaries for more than one health-risk behavior. Information about the, study design, population, sample size, health-risk behaviors, education variables, and academic outcome(s) for all research publications included in this review are available in the online-only appendices of this article on the Journal's website.

      Results

      The results are summarized for each health-risk behavior, including the extent to which the research findings are consistent or different. When an association or inverse association was not determined or not statistically significant, those findings are included in the behavior-specific sections below. Table 2 presents the number of studies included for each health-risk behavior, measures used for the variable of academic achievement, number of cross-sectional and longitudinal studies, and percentage of studies in each category that reported an inverse association between specified health-risk behaviors and one or more measure of academic achievement.
      Table 2Summary of published research (1985–2010) association of health-risk behaviors and academic achievement of school-aged youth
      Health-risk behaviorsNumber of published studiesMeasures for academic achievement matching selection criteriaOther measures for academic achievement included in studiesLongitudinal studies reporting an inverse associationCross-sectional studies reporting an inverse association
      1. Violence32
      One published study was both cross-sectional and longitudinal.
      GPA, grades, standardized test scores, grade-level retention, and years of school completedTeacher-rated educational engagement and educational aspirations13 of 14
      One published study was both cross-sectional and longitudinal.
      (92.9%)

      Range of length of studies: 1–10 years

      19 of 19
      One published study was both cross-sectional and longitudinal.
      (100%)
      2. Tobacco use28GPA, grades, standardized test scores, and grade-level retentionTeacher-rated educational engagement, academic stream in high school, and college intentions10 of 10 (100%)

      Range of length of studies: 10 months to 17 years
      18 of 18 (100%)
      3. Alcohol and other drug use44GPA, grades, standardized test scores, grade-level retention, high school graduation or GED and attainment of a college degreeHigh school class rank, academic stream in high school, on time/late high school graduation, college plans, and college entry20 of 21 (95.2%)

      Range of length of studies: 2–23 years
      23 of 23 (100%)
      4. Sexual risk22GPA, grades, standardized test scores, grade-level retention, high school graduation, and years of school completedHigh school class rank, plans for future schooling, school involvement, initiating college, and/or attending college12 of 12 (100%)

      Range of length of studies: 1 month to 11 years
      10 of 10 (100%)
      5. Inadequate physical activity13GPA, grades, and standardized test scoresSelf-reported chances of attending and/or graduating from college5 of 7 (71.4%)

      Range of length of studies: 3 months to 10 years
      4 of 6 (66.7%)
      6. Inadequate nutrition9GPA, grades, and standardized test scoresSchool attendance and tardiness4 of 4 (100%)

      Range of length of studies: 4 months to 10 years
      5 of 5 (100%)
      Total148
      While 122 publications in peer reviewed journals were included, 26 of the studies addressed more than one health-risk behavior.
      65 of 68 (95.6%)80 of 83 (96.4%)
      GPA = grade point average.
      a One published study was both cross-sectional and longitudinal.
      b While 122 publications in peer reviewed journals were included, 26 of the studies addressed more than one health-risk behavior.

      Violence-related risk behaviors and academic achievement

      Using the criteria described above, we selected 32 publications that examined the association between violence-related behaviors and academic performance. One of the 32 studies about the relationship of violent behaviors and academic achievement had both longitudinal and cross-sectional components (14 longitudinal plus 19 cross-sectional).
      Without exception, the cross-sectional studies (100%) revealed that students with higher academic performance (indicated by GPA, academic grades, standardized test scores, grade retention, or years of education completed) were significantly less likely to engage in or be victims of violent behaviors, compared with those with poorer academic performance [
      • Bachman R.
      • Peralta R.
      The relationship between drinking and violence in an adolescent population: Does gender matter?.
      ,
      • Bergman L.
      Dating violence among high school students.
      ,
      • Bergstein J.M.
      • Hemenway D.
      • Kennedy B.
      • et al.
      Guns in young hands: A survey of urban teenagers' attitudes and behaviors related to handgun violence.
      ,
      • Borowsky I.W.
      • Hogan M.
      • Ireland M.
      Adolescent sexual aggression: Risk and protective factors.
      ,
      • Brockenbrough K.K.
      • Cornell D.G.
      • Loper A.B.
      Aggressive attitudes among victims of violence at school.
      ,
      • Eisenberg M.E.
      • Neumark-Sztainer D.
      • Perry C.L.
      Peer harassment, school connectedness, and academic achievement.
      ,
      • Everett S.A.
      • Price J.H.
      Students' perceptions of violence in the public schools: The MetLife survey.
      ,
      • Feinberg M.E.
      • Ridenour T.A.
      • Greenberg M.T.
      Aggregating indices of risk and protection for adolescent behavior problems: The Communities That Care Youth Survey.
      ,
      • Felix E.D.
      • Furlong M.J.
      • Austin G.
      A cluster analytic investigation of school violence victimization among diverse students.
      ,
      • Furlong M.J.
      • Chung A.
      • Bates M.
      • Morrison R.L.
      Who are the victims of school violence? A comparison of student non-victims and multi-victims.
      ,
      • Glew G.M.
      • Fan M.Y.
      • Katon W.
      • et al.
      Bullying, psychosocial adjustment, and academic performance in elementary school.
      ,
      • Glew G.M.
      • Fan M.-Y.
      • Katon W.
      • Rivara F.P.
      Bullying and school safety.
      ,
      • Halpern C.T.
      • Oslak S.G.
      • Young M.L.
      • et al.
      Partner violence among adolescents in opposite-sex romantic relationships: Findings from the National Longitudinal Study of Adolescent Health.
      ,
      • Holt M.K.
      • Finkelhor D.
      • Kantor G.K.
      Multiple victimization experiences of urban elementary school students: Associations with psychological functioning and academic performance.
      ,
      • Juvonen J.
      • Nishina A.
      • Graham S.
      Peer harassment, psychological adjustment, and school functioning in early adolescence.
      ,
      • Resnick M.D.
      • Bearman P.S.
      • Blum R.W.
      • et al.
      Protecting adolescents from harm: Findings from the National Longitudinal Study on Adolescent Health.
      ,
      • Srabstein J.
      • Piazza T.
      Public health, safety and educational risks associated with bullying behaviors in American adolescents.
      ,
      • Telljohann S.K.
      • Price J.H.
      • Summers J.
      • et al.
      High school students' perceptions of nonconsensual sexual activity.
      ]. All but one of the longitudinal studies (92.9%) also reported an inverse association between academic performance and being either the victim or perpetrator of violence [
      • Borowsky I.W.
      • Ireland M.
      • Resnick M.D.
      Violence risk and protective factors among youth held back in school.
      ,
      • Borowsky I.W.
      • Ireland M.
      Predictors of future fight-related injury among adolescents.
      ,
      • Cleveland H.H.
      • Herrera V.M.
      • Stuewig J.
      Abusive males and abused females in adolescent relationships: Risk factor similarity and dissimilarity and the role of relationship seriousness.
      ,
      • Dishion T.J.
      • Nelson S.E.
      • Yasui M.
      Predicting early adolescent gang involvement from middle school adaptation.
      ,
      • Ellickson P.
      • Saner H.
      • McGuigan K.A.
      Profiles of violent youth: Substance use and other concurrent problems.
      ,
      • Ellickson P.L.
      • McGuigan K.A.
      Early predictors of adolescent violence.
      ,
      • Giang M.T.
      • Graham S.
      Using latent class analysis to identify aggressors and victims of peer harassment.
      ,
      • Graham S.
      • Bellmore A.D.
      • Mize J.
      Peer victimization, aggression, and their co-occurrence in middle school: Pathways to adjustment problems.
      ,
      • Herrenkohl T.I.
      • Maguin E.
      • Hill K.G.
      • et al.
      Developmental risk factors for youth violence.
      ,
      • Macmillan R.
      • Hagan J.
      Violence in the transition to adulthood: Adolescent victimization, education, and socioeconomic attainment in later life.
      ,
      • Schwartz D.
      • Gorman A.H.
      • Nakamoto J.
      • Toblin R.L.
      Victimization in the peer group and children's academic functioning.
      ,
      • Schwartz D.
      • Gorman A.H.
      • Dodge K.A.
      • et al.
      Friendships with peers who are low or high in aggression as moderators of the link between peer victimization and declines in academic functioning.
      ,
      • Wienke Totura C.M.
      • Green A.E.
      • Karver M.S.
      • Gesten E.L.
      Multiple informants in the assessment of psychological, behavioral, and academic correlates of bullying and victimization in middle school.
      ]. The longitudinal study that was an exception to this pattern of findings reported that standardized test scores (the variable the researchers used for academic achievement) were not associated with victimization [
      • Hanish L.D.
      • Guerra N.G.
      A longitudinal analysis of patterns of adjustment following peer victimization.
      ].
      Among the 32 selected publications related to violence, five specifically studied nonconsensual sexual activity and violence between consenting sexual partners [
      • Bergman L.
      Dating violence among high school students.
      ,
      • Borowsky I.W.
      • Hogan M.
      • Ireland M.
      Adolescent sexual aggression: Risk and protective factors.
      ,
      • Halpern C.T.
      • Oslak S.G.
      • Young M.L.
      • et al.
      Partner violence among adolescents in opposite-sex romantic relationships: Findings from the National Longitudinal Study of Adolescent Health.
      ,
      • Telljohann S.K.
      • Price J.H.
      • Summers J.
      • et al.
      High school students' perceptions of nonconsensual sexual activity.
      ,
      • Cleveland H.H.
      • Herrera V.M.
      • Stuewig J.
      Abusive males and abused females in adolescent relationships: Risk factor similarity and dissimilarity and the role of relationship seriousness.
      ]. Those studies consistently found an inverse association with academic achievement (measured by academic grades or GPA) for those being forced to engage in sexual activity and also for those who forced someone to engage in sexual activity.
      The longitudinal studies ranged in length from 1 to 10 years and provided the researchers with information about what might be antecedent behaviors. With data from an 8-year longitudinal study, researchers reported that low academic performance at ages 10, 14, and 16 years predicted violent behaviors at age 18 [
      • Herrenkohl T.I.
      • Maguin E.
      • Hill K.G.
      • et al.
      Developmental risk factors for youth violence.
      ]. In a 10-year longitudinal study with subjects between the ages of 11 and 27 years, victimization during adolescence had a negative effect on GPA at age 18, and also a negative effect on the highest level of education completed as adults [
      • Macmillan R.
      • Hagan J.
      Violence in the transition to adulthood: Adolescent victimization, education, and socioeconomic attainment in later life.
      ].

      Tobacco use–related risk behaviors and academic achievement

      In all 28 studies (100%), an inverse association between tobacco use and one or more of the variables used for academic achievement was reported [
      • Allison K.R.
      Academic stream and tobacco, alcohol, and cannabis use among Ontario high school students.
      ,
      • Feinberg M.E.
      • Ridenour T.A.
      • Greenberg M.T.
      Aggregating indices of risk and protection for adolescent behavior problems: The Communities That Care Youth Survey.
      ,
      • Resnick M.D.
      • Bearman P.S.
      • Blum R.W.
      • et al.
      Protecting adolescents from harm: Findings from the National Longitudinal Study on Adolescent Health.
      ,
      • Ansary N.S.
      • Luthar S.S.
      Distress and academic achievement among adolescents of affluence: A study of externalizing and internalizing problem behaviors and school performance.
      ,
      • Berg C.
      • Choi W.S.
      • Kaur H.
      • et al.
      The role of parenting, church attendance, and depression in adolescent smoking.
      ,
      • Bryant A.L.
      • Schulenberg J.E.
      • O'Malley P.M.
      • Johnston L.D.
      Understanding the links among school misbehavior, academic achievement, and cigarette use: A national panel study of adolescents.
      ,
      • Bryant A.L.
      • Schulenberg J.E.
      • O'Malley P.M.
      • et al.
      How academic achievement, attitudes, and behaviors relate to the course of substance use during adolescence: A 6-year, multiwave national longitudinal study.
      ,
      • Bryant A.L.
      • Zimmerman M.A.
      Examining the effects of academic beliefs and behaviors on changes in substance use among urban adolescents.
      ,
      • Carvajal S.C.
      • Granillo T.M.
      A prospective test of distal and proximal determinants of smoking initiation in early adolescents.
      ,
      • Cox R.G.
      • Zhang L.
      • Johnson W.D.
      • Bender D.R.
      Academic performance and substance use: Findings from a state survey of public high school students.
      ,
      • Ellickson P.L.
      • Tucker J.S.
      • Klein D.J.
      High-risk behaviors associated with early smoking: Results from a 5-year follow-up.
      ,
      • Farrell A.D.
      • Danish S.J.
      • Howard C.W.
      Relationship between drug use and other problem behaviors in urban adolescents.
      ,
      • Georgiades K.
      • Boyle M.H.
      Adolescent tobacco and cannabis use: Young adult outcomes from the Ontario Child Health Study.
      ,
      • Gottlieb A.
      • Pope S.K.
      • Rickert V.I.
      • Hardin B.H.
      Patterns of smokeless tobacco use by young adolescents.
      ,
      • Griffin K.W.
      • Botvin G.J.
      • Doyle M.M.
      • et al.
      A six-year follow-up study of determinants of heavy cigarette smoking among high-school seniors.
      ,
      • He K.
      • Kramer E.
      • Houser R.F.
      • et al.
      Defining and understanding healthy lifestyles choices for adolescents.
      ,
      • Jackson C.
      Initial and experimental stages of tobacco and alcohol use during late childhood: relation to peer, parent, and personal risk factors.
      ,
      • Jackson C.
      • Bee-Gates D.J.
      • Henriksen L.
      Authoritative parenting, child competencies, and initiation of cigarette smoking.
      ,
      • Jeynes W.H.
      The relationship between the consumption of various drugs by adolescents and their academic achievement.
      ,
      • Khuder S.A.
      • Price J.H.
      • Jordan T.
      • et al.
      Cigarette smoking among adolescents in northwest Ohio: Correlates of prevalence and age at onset.
      ,
      • Luthar S.S.
      • Ansary N.S.
      Dimensions of adolescent rebellion: Risks for academic failure among high- and low-income youth.
      ,
      • Lynne-Landsman S.D.
      • Bradshaw C.P.
      • Ialongo N.S.
      Testing a developmental cascade model of adolescent substance use trajectories and young adult adjustment.
      ,
      • Mun E.Y.
      • Windle M.
      • Schainker L.M.
      A model-based cluster analysis approach to adolescent problem behaviors among young adult outcomes.
      ,
      • Scal P.
      • Ireland M.
      • Borowsky I.W.
      Smoking among American adolescents: A risk and protective factor analysis.
      ,
      • Soldz S.
      • Cui X.
      A risk factor index predicting adolescent cigarette smoking: A 7-year longitudinal study.
      ,
      • Tucker J.S.
      • Ellickson P.L.
      • Klein D.J.
      Predictors of the transition to regular smoking during adolescence and young adulthood.
      ,
      • Tucker J.S.
      • Martinez J.F.
      • Ellickson P.L.
      • Edelen M.O.
      Temporal associations of cigarette smoking with social influences, academic performance, and delinquency: A four-wave longitudinal study from ages 13 to 23.
      ,
      • Wright D.R.
      • Fitzpatrick K.M.
      Psychosocial correlates of substance use behaviors among African American youth.
      ]. The variables used for academic achievement in the tobacco use–related papers were GPA, standardized test scores, or grade-level retention. Researchers consistently reported that students with higher academic achievement were significantly less likely to use tobacco, compared with their peers with lower grades or standardized test scores.
      All 10 of the longitudinal studies (ranging from 10 months to 17 years in length) reported that those who used tobacco performed less well academically in school than their non–tobacco-using peers [
      • Ansary N.S.
      • Luthar S.S.
      Distress and academic achievement among adolescents of affluence: A study of externalizing and internalizing problem behaviors and school performance.
      ,
      • Bryant A.L.
      • Schulenberg J.E.
      • O'Malley P.M.
      • Johnston L.D.
      Understanding the links among school misbehavior, academic achievement, and cigarette use: A national panel study of adolescents.
      ,
      • Bryant A.L.
      • Schulenberg J.E.
      • O'Malley P.M.
      • et al.
      How academic achievement, attitudes, and behaviors relate to the course of substance use during adolescence: A 6-year, multiwave national longitudinal study.
      ,
      • Bryant A.L.
      • Zimmerman M.A.
      Examining the effects of academic beliefs and behaviors on changes in substance use among urban adolescents.
      ,
      • Carvajal S.C.
      • Granillo T.M.
      A prospective test of distal and proximal determinants of smoking initiation in early adolescents.
      ,
      • Ellickson P.L.
      • Tucker J.S.
      • Klein D.J.
      High-risk behaviors associated with early smoking: Results from a 5-year follow-up.
      ,
      • Georgiades K.
      • Boyle M.H.
      Adolescent tobacco and cannabis use: Young adult outcomes from the Ontario Child Health Study.
      ,
      • Griffin K.W.
      • Botvin G.J.
      • Doyle M.M.
      • et al.
      A six-year follow-up study of determinants of heavy cigarette smoking among high-school seniors.
      ,
      • Lynne-Landsman S.D.
      • Bradshaw C.P.
      • Ialongo N.S.
      Testing a developmental cascade model of adolescent substance use trajectories and young adult adjustment.
      ,
      • Mun E.Y.
      • Windle M.
      • Schainker L.M.
      A model-based cluster analysis approach to adolescent problem behaviors among young adult outcomes.
      ]. Data were collected in three of the longitudinal studies about years of education completed; results of all three indicated that cigarette users completed fewer years of education than nonusers [
      • Ellickson P.L.
      • Tucker J.S.
      • Klein D.J.
      High-risk behaviors associated with early smoking: Results from a 5-year follow-up.
      ,
      • Georgiades K.
      • Boyle M.H.
      Adolescent tobacco and cannabis use: Young adult outcomes from the Ontario Child Health Study.
      ,
      • Mun E.Y.
      • Windle M.
      • Schainker L.M.
      A model-based cluster analysis approach to adolescent problem behaviors among young adult outcomes.
      ].

      Alcohol and other drug-related behaviors and academic achievement

      A total of 44 studies about the association of alcohol and other drug-related behaviors and academic achievement were included [
      • Allison K.R.
      Academic stream and tobacco, alcohol, and cannabis use among Ontario high school students.
      ,
      • Feinberg M.E.
      • Ridenour T.A.
      • Greenberg M.T.
      Aggregating indices of risk and protection for adolescent behavior problems: The Communities That Care Youth Survey.
      ,
      • Resnick M.D.
      • Bearman P.S.
      • Blum R.W.
      • et al.
      Protecting adolescents from harm: Findings from the National Longitudinal Study on Adolescent Health.
      ,
      • Ansary N.S.
      • Luthar S.S.
      Distress and academic achievement among adolescents of affluence: A study of externalizing and internalizing problem behaviors and school performance.
      ,
      • Bryant A.L.
      • Schulenberg J.E.
      • O'Malley P.M.
      • et al.
      How academic achievement, attitudes, and behaviors relate to the course of substance use during adolescence: A 6-year, multiwave national longitudinal study.
      ,
      • Bryant A.L.
      • Zimmerman M.A.
      Examining the effects of academic beliefs and behaviors on changes in substance use among urban adolescents.
      ,
      • Cox R.G.
      • Zhang L.
      • Johnson W.D.
      • Bender D.R.
      Academic performance and substance use: Findings from a state survey of public high school students.
      ,
      • Farrell A.D.
      • Danish S.J.
      • Howard C.W.
      Relationship between drug use and other problem behaviors in urban adolescents.
      ,
      • Georgiades K.
      • Boyle M.H.
      Adolescent tobacco and cannabis use: Young adult outcomes from the Ontario Child Health Study.
      ,
      • He K.
      • Kramer E.
      • Houser R.F.
      • et al.
      Defining and understanding healthy lifestyles choices for adolescents.
      ,
      • Jackson C.
      Initial and experimental stages of tobacco and alcohol use during late childhood: relation to peer, parent, and personal risk factors.
      ,
      • Jeynes W.H.
      The relationship between the consumption of various drugs by adolescents and their academic achievement.
      ,
      • Luthar S.S.
      • Ansary N.S.
      Dimensions of adolescent rebellion: Risks for academic failure among high- and low-income youth.
      ,
      • Lynne-Landsman S.D.
      • Bradshaw C.P.
      • Ialongo N.S.
      Testing a developmental cascade model of adolescent substance use trajectories and young adult adjustment.
      ,
      • Mun E.Y.
      • Windle M.
      • Schainker L.M.
      A model-based cluster analysis approach to adolescent problem behaviors among young adult outcomes.
      ,
      • Almodovar A.
      • Tomaka J.
      • Thompson S.
      • et al.
      Risk and protective factors among high school students on the US/Mexico Border.
      ,
      • Chatterji P.
      Illicit drug use and educational attainment.
      ,
      • Clark T.T.
      • Belgrave F.Z.
      • Nasim A.
      Risk and protective factors for substance use among urban African American adolescents considered high-risk.
      ,
      • Cook P.J.
      • Moore M.J.
      Drinking and schooling.
      ,
      • Crano W.D.
      The at-risk adolescent marijuana nonuser: Expanding the standard distinction.
      ,
      • Crosnoe R.
      Academic and health-related trajectories in adolescence: The intersection of gender and athletics.
      ,
      • Dee T.S.
      • Evans W.N.
      Teen drinking and educational attainment: Evidence from two-sample instrumental variables estimates.
      ,
      • Ellickson P.L.
      • Tucker J.S.
      • Klein D.J.
      Ten-year prospective study of public health problems associated with early drinking.
      ,
      • Griffin B.A.
      • Ramchand R.
      • Edelen M.O.
      • et al.
      Associations between abstinence in adolescence and economic and educational outcomes seven years later among high-risk youth.
      ,
      • Henry K.L.
      Academic achievement and adolescent drug use: An examination of reciprocal effects and correlated growth trajectories.
      ,
      • Henry K.L.
      • Smith E.A.
      • Caldwell L.L.
      Deterioration of academic achievement and marijuana use onset among rural adolescents.
      ,
      • Hillman S.B.
      • Haskin J.M.
      Personality and drug abstention in adolescents.
      ,
      • Kandel D.B.
      • Davies M.
      High school students who use crack and other drugs.
      ,
      • Kaplan C.P.
      • Zabkiewicz D.
      • McPhee S.J.
      • et al.
      Health-compromising behaviors among Vietnamese adolescents: The role of education and extracurricular activities.
      ,
      • King K.M.
      • Meehan B.T.
      • Trim R.S.
      • Chassin L.
      Marker or mediator? The effects of adolescent substance use on young adult educational attainment.
      ,
      • Mackesy-Amiti M.E.
      • Fendrich M.
      Trends in inhalant use among high school students in Illinois: 1993-1995.
      ,
      • Martins S.S.
      • Alexandre P.K.
      The association of Ecstasy use and academic achievement among adolescent in two U.S. national surveys.
      ,
      • McKinnon S.A.
      • O'Rourke K.M.
      • Thompson S.E.
      • Berumen J.H.
      Alcohol use and abuse by adolescents: The impact of living in a border community.
      ,
      • Miller J.W.
      • Naim T.S.
      • Brewer R.D.
      • Jones S.E.
      Binge drinking and associated health risk behaviors among high school students.
      ,
      • Myers M.G.
      • Aarons G.A.
      • Tomlinson K.
      • Stein M.B.
      Social anxiety, negative affectivity, and substance use among high school students.
      ,
      • Paulson M.J.
      • Coombs R.H.
      • Richardson M.A.
      School performance, academic aspirations, and drug use among children and adolescents.
      ,
      • Renna F.
      The economic cost of teen drinking: Late graduation and lowered earnings.
      ,
      • Ryan A.K.
      The lasting effects of marijuana use on educational attainment in midlife.
      ,
      • Schepis T.S.
      • Krishnan-Sarin S.
      Characterizing adolescent prescription misusers: A population-based study.
      ,
      • Spirito A.
      • Barnett N.P.
      • Lewander W.
      • et al.
      Risks associated with alcohol-positive status among adolescents in the emergency department: A matched case-control study.
      ,
      • Stevens M.M.
      • Freeman D.H.
      • Mott L.
      • Youells F.
      Three-year results of prevention programs on marijuana use: The New Hampshire study.
      ,
      • Thomas B.S.
      • Hsiu L.T.
      The role of selected risk factors in predicting adolescent drug use and its adverse consequences.
      ,
      • Yarnold B.M.
      The use of alcohol by Miami's adolescent public school students 1992: Peers, risk-taking, and availability as central forces.
      ]. The variables used for academic achievement in these studies were GPA, grades, standardized test scores, grade-level retention, and years of schooling (high school graduation or passing the General Educational Development Test).
      Of the 44 studies, 23 were cross-sectional [
      • Allison K.R.
      Academic stream and tobacco, alcohol, and cannabis use among Ontario high school students.
      ,
      • Feinberg M.E.
      • Ridenour T.A.
      • Greenberg M.T.
      Aggregating indices of risk and protection for adolescent behavior problems: The Communities That Care Youth Survey.
      ,
      • Cox R.G.
      • Zhang L.
      • Johnson W.D.
      • Bender D.R.
      Academic performance and substance use: Findings from a state survey of public high school students.
      ,
      • Farrell A.D.
      • Danish S.J.
      • Howard C.W.
      Relationship between drug use and other problem behaviors in urban adolescents.
      ,
      • He K.
      • Kramer E.
      • Houser R.F.
      • et al.
      Defining and understanding healthy lifestyles choices for adolescents.
      ,
      • Jackson C.
      Initial and experimental stages of tobacco and alcohol use during late childhood: relation to peer, parent, and personal risk factors.
      ,
      • Jackson C.
      • Bee-Gates D.J.
      • Henriksen L.
      Authoritative parenting, child competencies, and initiation of cigarette smoking.
      ,
      • Jeynes W.H.
      The relationship between the consumption of various drugs by adolescents and their academic achievement.
      ,
      • Luthar S.S.
      • Ansary N.S.
      Dimensions of adolescent rebellion: Risks for academic failure among high- and low-income youth.
      ,
      • Almodovar A.
      • Tomaka J.
      • Thompson S.
      • et al.
      Risk and protective factors among high school students on the US/Mexico Border.
      ,
      • Clark T.T.
      • Belgrave F.Z.
      • Nasim A.
      Risk and protective factors for substance use among urban African American adolescents considered high-risk.
      ,
      • Hillman S.B.
      • Haskin J.M.
      Personality and drug abstention in adolescents.
      ,
      • Kandel D.B.
      • Davies M.
      High school students who use crack and other drugs.
      ,
      • Kaplan C.P.
      • Zabkiewicz D.
      • McPhee S.J.
      • et al.
      Health-compromising behaviors among Vietnamese adolescents: The role of education and extracurricular activities.
      ,
      • McKinnon S.A.
      • O'Rourke K.M.
      • Thompson S.E.
      • Berumen J.H.
      Alcohol use and abuse by adolescents: The impact of living in a border community.
      ,
      • Miller J.W.
      • Naim T.S.
      • Brewer R.D.
      • Jones S.E.
      Binge drinking and associated health risk behaviors among high school students.
      ,
      • Myers M.G.
      • Aarons G.A.
      • Tomlinson K.
      • Stein M.B.
      Social anxiety, negative affectivity, and substance use among high school students.
      ,
      • Renna F.
      The economic cost of teen drinking: Late graduation and lowered earnings.
      ,
      • Ryan A.K.
      The lasting effects of marijuana use on educational attainment in midlife.
      ,
      • Schepis T.S.
      • Krishnan-Sarin S.
      Characterizing adolescent prescription misusers: A population-based study.
      ,
      • Spirito A.
      • Barnett N.P.
      • Lewander W.
      • et al.
      Risks associated with alcohol-positive status among adolescents in the emergency department: A matched case-control study.
      ,
      • Thomas B.S.
      • Hsiu L.T.
      The role of selected risk factors in predicting adolescent drug use and its adverse consequences.
      ,
      • Yarnold B.M.
      The use of alcohol by Miami's adolescent public school students 1992: Peers, risk-taking, and availability as central forces.
      ]. All of the cross-sectional studies reported an inverse association between academic achievement and binge drinking; drinking to get drunk; using inhalants, marijuana, or other illicit drugs; or misusing prescription medications. Among the studies about alcohol use, six cross-sectional studies [
      • Cox R.G.
      • Zhang L.
      • Johnson W.D.
      • Bender D.R.
      Academic performance and substance use: Findings from a state survey of public high school students.
      ,
      • Jeynes W.H.
      The relationship between the consumption of various drugs by adolescents and their academic achievement.
      ,
      • Almodovar A.
      • Tomaka J.
      • Thompson S.
      • et al.
      Risk and protective factors among high school students on the US/Mexico Border.
      ,
      • Martins S.S.
      • Alexandre P.K.
      The association of Ecstasy use and academic achievement among adolescent in two U.S. national surveys.
      ,
      • McKinnon S.A.
      • O'Rourke K.M.
      • Thompson S.E.
      • Berumen J.H.
      Alcohol use and abuse by adolescents: The impact of living in a border community.
      ,
      • Myers M.G.
      • Aarons G.A.
      • Tomlinson K.
      • Stein M.B.
      Social anxiety, negative affectivity, and substance use among high school students.
      ] and three, longitudinal studies [
      • Bryant A.L.
      • Zimmerman M.A.
      Examining the effects of academic beliefs and behaviors on changes in substance use among urban adolescents.
      ,
      • Cook P.J.
      • Moore M.J.
      Drinking and schooling.
      ,
      • Ellickson P.L.
      • Tucker J.S.
      • Klein D.J.
      Ten-year prospective study of public health problems associated with early drinking.
      ] differentiated drinking alcohol from heavy drinking, binge drinking and drinking to get drunk. Analyses in all nine of those studies demonstrated that binge drinking and drinking to get drunk were associated with lower academic achievement, whereas the achievement of those who drank alcohol (but did not binge or drink to get drunk) was not significantly lower than the achievement of those who abstained from drinking alcohol.
      Among the 44 studies about alcohol and other drug use and academic achievement, there were 21 longitudinal studies ranging from 2 to 23 years in length; five of the longitudinal studies spanned 10–23 years. One study found that 10th-grade students who reported being heavy drinkers (five or more drinks in a row in the past month) were 5 percentage points less likely to enter college, while seniors who were heavy drinkers were 7–9 percentage points less likely to enter college, compared with their counterparts who were not heavy drinkers [
      • Dee T.S.
      • Evans W.N.
      Teen drinking and educational attainment: Evidence from two-sample instrumental variables estimates.
      ]. One of the 21 longitudinal studies did not report a statistically significant inverse association between use of alcohol or other drugs and academic achievement. That study focused primarily on determining differences between the alcohol consumption of students involved in athletic extracurricular activities and those involved in other school activities. For both groups of students (those participating in athletic and non-athletic extracurricular activities), the author(s) reported that alcohol use among students earning As and Bs was slightly less (but not at a statistically significant level) than use among students with academic grades of C or below [
      • Yarnold B.M.
      The use of alcohol by Miami's adolescent public school students 1992: Peers, risk-taking, and availability as central forces.
      ].
      Results of longitudinal studies provided information about the reciprocal effects of alcohol and other drug use on years of education completed, and also identified health-risk behaviors that might be considered antecedent. For example, in one study, researchers reported that higher levels of drug use at age 13 were negatively related to both college attendance and college degree completion reported at age 25 [
      • King K.M.
      • Meehan B.T.
      • Trim R.S.
      • Chassin L.
      Marker or mediator? The effects of adolescent substance use on young adult educational attainment.
      ]. In another study, adults in the last wave of a 10-year longitudinal study who reported cannabis use only during adolescence had completed .72 years less of education, compared with nonusers; those who reported use of cannabis in both adolescence and adulthood completed 1.16 years less education compared with their counterparts who did not use cannabis [
      • Georgiades K.
      • Boyle M.H.
      Adolescent tobacco and cannabis use: Young adult outcomes from the Ontario Child Health Study.
      ]. A 23-year longitudinal study about marijuana use provided information about the long-term association of marijuana use with years of educational attainment. Data were collected from 1979 until 2002, beginning when the subjects were 14–22 years of age. When subjects were 37–45 years of age, those who persisted using from adolescence into adulthood reported significantly fewer years of education completed (11.9 years), compared with nonusers (13.1 years). Furthermore, higher frequency of marijuana use was associated with fewer years of education completed for both those whose use was limited to adolescence (12.4 years) and those whose use persisted with high frequency into adulthood (11.9 years) [
      • Ryan A.K.
      The lasting effects of marijuana use on educational attainment in midlife.
      ].

      Sexual behaviors increasing risk of pregnancy and STD, and academic achievement

      In 22 publications with research about the relationship of academic achievement and sexual risk behaviors, more than half (12) were longitudinal studies [
      • Mun E.Y.
      • Windle M.
      • Schainker L.M.
      A model-based cluster analysis approach to adolescent problem behaviors among young adult outcomes.
      ,
      • Capaldi D.M.
      • Crosby L.
      • Stoolmiller M.
      Predicting the timing of first sexual intercourse for at-risk adolescent males.
      ,
      • Chen A.C.
      • Thompson E.A.
      • Morrison-Beedy D.
      Multi-system influences on adolescent risky sexual behavior.
      ,
      • Ford C.A.
      • Pence B.W.
      • Miller W.C.
      • et al.
      Predicting adolescents' longitudinal risk for sexually transmitted infection: Results from the National Longitudinal Study of Adolescent Health.
      ,
      • Laflin M.T.
      • Wang J.
      • Barry M.
      A longitudinal study of adolescent transition from virgin to nonvirgin status.
      ,
      • Moore K.A.
      • Manlove J.
      • Glei D.A.
      • Morrison D.R.
      Nonmarital school-age motherhood: Family, individual, and school characteristics.
      ,
      • Sabia J.J.
      • Rees D.I.
      The effect of sexual abstinence on females' educational attainment.
      ,
      • Santelli J.S.
      • Kaiser J.
      • Hirsch L.
      • et al.
      Initiation of sexual intercourse among middle school adolescents: The influence of psychosocial factors.
      ,
      • Scaramella L.V.
      • Conger R.D.
      • Simons R.L.
      • Whitbeck L.B.
      Predicting risk for pregnancy by late adolescence: A social contextual perspective.
      ,
      • Schvaneveldt P.L.
      • Miller B.C.
      • Berry E.H.
      • Lee T.R.
      Academic goals, achievement, and age at first sexual intercourse.
      ,
      • Spriggs A.L.
      • Halpern C.T.
      Timing of sexual debut and initiation of postsecondary education by early adulthood.
      ,
      • Tubman J.G.
      • Windle M.
      • Windle R.C.
      The onset and cross-temporal patterning of sexual intercourse in middle adolescence: Prospective relations with behavioral and emotional problems.
      ]. The remaining 10 studies were cross-sectional [
      • Resnick M.D.
      • Bearman P.S.
      • Blum R.W.
      • et al.
      Protecting adolescents from harm: Findings from the National Longitudinal Study on Adolescent Health.
      ,
      • Farrell A.D.
      • Danish S.J.
      • Howard C.W.
      Relationship between drug use and other problem behaviors in urban adolescents.
      ,
      • He K.
      • Kramer E.
      • Houser R.F.
      • et al.
      Defining and understanding healthy lifestyles choices for adolescents.
      ,
      • Raine T.R.
      • Jenkins R.
      • Aarons S.J.
      • et al.
      Sociodemographic correlates of virginity in seventh-grade black and Latino students.
      ,
      • Davis E.C.
      • Friel L.V.
      Adolescent sexuality: Disentangling the effects of family structure and family context.
      ,
      • Doijanac R.F.
      • Zimmerman M.A.
      Psychosocial factors and high-risk sexual behavior: Race differences among urban adolescents.
      ,
      • Holden G.W.
      • Nelson P.B.
      Cognitive, psychosocial, and reported sexual behavior differences between pregnant and nonpregnant adolescents.
      ,
      • Manning W.D.
      • Longmore M.A.
      • Giordano P.C.
      The relationship context of contraceptive use at first intercourse.
      ,
      • Martin A.
      • Ruchkin V.
      • Caminis A.
      • et al.
      Early to bed: A study of adaptation among sexually active urban adolescent girls younger than age sixteen.
      ,
      • Miller B.C.
      • Sneesby K.R.
      Educational correlates of adolescents' sexual attitudes and behavior.
      ].
      All of the cross-sectional and longitudinal studies reported an inverse relationship between sexual risk behaviors and academic achievement. Measures used for academic achievement required to be included in this review were GPA and standardized test scores, grade-level retention, and high school graduation.
      Data about sexual debut (age of first sexual intercourse or loss of virginity) were collected and used as a variable in 10 of the studies [
      • Resnick M.D.
      • Bearman P.S.
      • Blum R.W.
      • et al.
      Protecting adolescents from harm: Findings from the National Longitudinal Study on Adolescent Health.
      ,
      • Capaldi D.M.
      • Crosby L.
      • Stoolmiller M.
      Predicting the timing of first sexual intercourse for at-risk adolescent males.
      ,
      • Laflin M.T.
      • Wang J.
      • Barry M.
      A longitudinal study of adolescent transition from virgin to nonvirgin status.
      ,
      • Raine T.R.
      • Jenkins R.
      • Aarons S.J.
      • et al.
      Sociodemographic correlates of virginity in seventh-grade black and Latino students.
      ,
      • Sabia J.J.
      • Rees D.I.
      The effect of sexual abstinence on females' educational attainment.
      ,
      • Santelli J.S.
      • Kaiser J.
      • Hirsch L.
      • et al.
      Initiation of sexual intercourse among middle school adolescents: The influence of psychosocial factors.
      ,
      • Schvaneveldt P.L.
      • Miller B.C.
      • Berry E.H.
      • Lee T.R.
      Academic goals, achievement, and age at first sexual intercourse.
      ,
      • Spriggs A.L.
      • Halpern C.T.
      Timing of sexual debut and initiation of postsecondary education by early adulthood.
      ,
      • Tubman J.G.
      • Windle M.
      • Windle R.C.
      The onset and cross-temporal patterning of sexual intercourse in middle adolescence: Prospective relations with behavioral and emotional problems.
      ,
      • Davis E.C.
      • Friel L.V.
      Adolescent sexuality: Disentangling the effects of family structure and family context.
      ]; only one of those studies specified opposite or same-sex intercourse [
      • Capaldi D.M.
      • Crosby L.
      • Stoolmiller M.
      Predicting the timing of first sexual intercourse for at-risk adolescent males.
      ]. In all 10 studies, earlier age of sexual debut was inversely associated with academic achievement, measured by grades, grade-level retention, or standardized test scores; in three of the studies, analyses also showed that increases in years of educational attainment (graduating from high school or attending college) were positively associated with delaying first sexual intercourse [
      • Sabia J.J.
      • Rees D.I.
      The effect of sexual abstinence on females' educational attainment.
      ,
      • Schvaneveldt P.L.
      • Miller B.C.
      • Berry E.H.
      • Lee T.R.
      Academic goals, achievement, and age at first sexual intercourse.
      ,
      • Spriggs A.L.
      • Halpern C.T.
      Timing of sexual debut and initiation of postsecondary education by early adulthood.
      ].
      Four of the 22 studies addressed the extent to which other health-risk behaviors such as tobacco, alcohol, and other drug use were correlated with risky sexual behaviors [
      • Resnick M.D.
      • Bearman P.S.
      • Blum R.W.
      • et al.
      Protecting adolescents from harm: Findings from the National Longitudinal Study on Adolescent Health.
      ,
      • Farrell A.D.
      • Danish S.J.
      • Howard C.W.
      Relationship between drug use and other problem behaviors in urban adolescents.
      ,
      • He K.
      • Kramer E.
      • Houser R.F.
      • et al.
      Defining and understanding healthy lifestyles choices for adolescents.
      ,
      • Mun E.Y.
      • Windle M.
      • Schainker L.M.
      A model-based cluster analysis approach to adolescent problem behaviors among young adult outcomes.
      ]. Those multiple-risk studies provided information about patterns of behavior, trajectories of behavior during adolescence, and clustering of risk behaviors that negatively affect academic achievement.

      Physical inactivity–related risk behaviors

      Using the selection criteria, we included in this review 13 studies published in peer-reviewed journals about the relationship of physical inactivity and academic achievement. Of the 13, seven were longitudinal studies [
      • Crosnoe R.
      Academic and health-related trajectories in adolescence: The intersection of gender and athletics.
      ,
      • Carlson S.A.
      • Fulton J.E.
      • Lee S.M.
      • et al.
      Physical education and academic achievement in elementary school: Data from the Early Childhood Longitudinal Study.
      ,
      • Fejgin N.
      Participation in high school competitive sports: A subversion of school mission or contribution to academic goals?.
      ,
      • Nansel T.R.
      • Huang T.K.
      • Rovner A.J.
      • Sanders-Butler Y.
      Association of school performance indicators with implementation of the Health Kids, Smart Kinds program: Case study.
      ,
      • Reed J.A.
      • Einstein G.
      • Hahn E.
      • et al.
      Examining the impact of integrating physical activity on fluid intelligence and academic performance in an elementary school setting: A preliminary investigation.
      ,
      • Sallis J.F.
      • McKenzie T.L.
      • Kolody B.
      • et al.
      Effects of health-related physical education on academic achievement: Project SPARK.
      ,
      • Shephard R.J.
      Habitual physical activity and academic performance.
      ], whereas the remaining six studies were cross-sectional [
      • Kaplan C.P.
      • Zabkiewicz D.
      • McPhee S.J.
      • et al.
      Health-compromising behaviors among Vietnamese adolescents: The role of education and extracurricular activities.
      ,
      • Chomitz V.R.
      • Slining M.M.
      • McGowan R.J.
      • et al.
      Is there a relationship between physical fitness and academic achievement? Positive results from public school children in the northeastern United States.
      ,
      • Coe D.P.
      • Pivarnik J.M.
      • Womack C.J.
      • et al.
      Effect of physical education and activity levels on academic achievement in children.
      ,
      • Fisher M.
      • Juszczak L.
      • Friedman S.B.
      Sports participation in an urban high school: Academic and psychologic correlates.
      ,
      • Fox C.K.
      • Barr-Anderson D.
      • Neumark-Sztainer D.
      • Wall M.
      Physical activity and sports team participation: Associations with academic outcomes in middle school and high school students.
      ,
      • Tremblay M.S.
      • Inman J.W.
      • Williams J.D.
      The relationship between physical activity, self-esteem, and academic achievement in 12-year-old children.
      ]. Review of these studies indicated that 71.4% of the longitudinal and 66.7% of the cross-sectional studies reported an inverse relationship between physical inactivity and academic achievement, or a positive association between the extent of being physically active and academic achievement. In all the studies, the data collected about time spent being physically active were limited to school activities (i.e., during the instructional day or while participating on school athletic teams). Measures of academic achievement used in the selected studies were GPA, grades, and standardized test scores.
      Four of the research studies were designed to determine whether grades or standardized test scores were negatively affected by using additional time during the instructional day for physical education. Results of those four studies showed that there was no negative impact on standardized test scores when additional instructional time was spent on physical education [
      • Carlson S.A.
      • Fulton J.E.
      • Lee S.M.
      • et al.
      Physical education and academic achievement in elementary school: Data from the Early Childhood Longitudinal Study.
      ,
      • Reed J.A.
      • Einstein G.
      • Hahn E.
      • et al.
      Examining the impact of integrating physical activity on fluid intelligence and academic performance in an elementary school setting: A preliminary investigation.
      ,
      • Sallis J.F.
      • McKenzie T.L.
      • Kolody B.
      • et al.
      Effects of health-related physical education on academic achievement: Project SPARK.
      ,
      • Shephard R.J.
      Habitual physical activity and academic performance.
      ].
      The relationship of GPA with the time spent in moderate to vigorous physical activity during the school day was reported in a cross-sectional study among 4,746 middle and high school students. Moderate to vigorous physical activity was positively associated with higher GPAs of both males and females [
      • Fox C.K.
      • Barr-Anderson D.
      • Neumark-Sztainer D.
      • Wall M.
      Physical activity and sports team participation: Associations with academic outcomes in middle school and high school students.
      ]. However, another cross-sectional study failed to find a statistically significant relationship between physical activity during the school day and academic performance measured by standardized test scores in reading and mathematics [
      • Tremblay M.S.
      • Inman J.W.
      • Williams J.D.
      The relationship between physical activity, self-esteem, and academic achievement in 12-year-old children.
      ].
      The results of four studies about whether participation in competitive athletics has a positive effect on academic performance were mixed [
      • Crosnoe R.
      Academic and health-related trajectories in adolescence: The intersection of gender and athletics.
      ,
      • Fejgin N.
      Participation in high school competitive sports: A subversion of school mission or contribution to academic goals?.
      ,
      • Fisher M.
      • Juszczak L.
      • Friedman S.B.
      Sports participation in an urban high school: Academic and psychologic correlates.
      ,
      • Fox C.K.
      • Barr-Anderson D.
      • Neumark-Sztainer D.
      • Wall M.
      Physical activity and sports team participation: Associations with academic outcomes in middle school and high school students.
      ]. One study reported no significant association between academic grades and participation in school-sponsored sports [
      • Fisher M.
      • Juszczak L.
      • Friedman S.B.
      Sports participation in an urban high school: Academic and psychologic correlates.
      ]. A 3-year longitudinal study reported little change in GPAs of both male and female athletes; however, the GPAs of male non-athletes decreased during the same period [
      • Crosnoe R.
      Academic and health-related trajectories in adolescence: The intersection of gender and athletics.
      ]. In a sample of 4,746 students in grades 7–12, researchers found that middle school boys and high school boys and girls who participated in sports teams had higher GPAs than their counterparts who did not participate in sports teams [
      • Fox C.K.
      • Barr-Anderson D.
      • Neumark-Sztainer D.
      • Wall M.
      Physical activity and sports team participation: Associations with academic outcomes in middle school and high school students.
      ]. In longitudinal research involving more than 40,000 eighth and 10th graders, students involved in competitive sports had significantly higher grades compared with students not involved in sports teams [
      • Fejgin N.
      Participation in high school competitive sports: A subversion of school mission or contribution to academic goals?.
      ].

      Nutrition-related risk behaviors and academic achievement

      All of the nine studies included in this review reported an inverse relationship between inadequate nutrition and academic achievement [
      • Nansel T.R.
      • Huang T.K.
      • Rovner A.J.
      • Sanders-Butler Y.
      Association of school performance indicators with implementation of the Health Kids, Smart Kinds program: Case study.
      ,
      • Alaimo K.
      • Olson C.M.
      • Frongillo E.A.
      Food insufficiency and American school-aged children's cognitive, academic, and psychosocial development.
      ,
      • Kleinman R.E.
      • Hall S.
      • Green H.
      • et al.
      Diet, breakfast, and academic performance in children.
      ,
      • Kleinman R.E.
      • Murphy J.M.
      • Little M.
      • et al.
      Hunger in children in the United States: Potential behavioral and emotional correlates.
      ,
      • MacLellan D.
      • Taylor J.
      • Wood K.
      Food intake and academic performance among adolescents.
      ,
      • Meyers A.F.
      • Sampson A.E.
      • Weitzman M.
      • et al.
      School breakfast program and school performance.
      ,
      • Murphy J.M.
      • Pagano M.E.
      • Nachmani J.
      • et al.
      The relationship of school breakfast to psychosocial and academic functioning: Cross-sectional and longitudinal observations in an inner-city school sample.
      ,
      • Neumark-Sztainer D.
      • Story M.
      • Dixon L.B.
      • et al.
      Correlates of inadequate consumption of dairy products among adolescents.
      ,
      • Neumark-Sztainer D.
      • Story M.
      • Resnick M.D.
      • Blum R.W.
      Correlates of inadequate fruit and vegetable consumption among adolescents.
      ]. One of the studies conducted by Kleinman and team [
      • Kleinman R.E.
      • Hall S.
      • Green H.
      • et al.
      Diet, breakfast, and academic performance in children.
      ] used a sample of 97, and not 100.
      The effect of participation in school breakfast or lunch programs on academic achievement was analyzed in four studies ranging from 4 months to 10 years in length [
      • Nansel T.R.
      • Huang T.K.
      • Rovner A.J.
      • Sanders-Butler Y.
      Association of school performance indicators with implementation of the Health Kids, Smart Kinds program: Case study.
      ,
      • Kleinman R.E.
      • Hall S.
      • Green H.
      • et al.
      Diet, breakfast, and academic performance in children.
      ,
      • Meyers A.F.
      • Sampson A.E.
      • Weitzman M.
      • et al.
      School breakfast program and school performance.
      ,
      • Murphy J.M.
      • Pagano M.E.
      • Nachmani J.
      • et al.
      The relationship of school breakfast to psychosocial and academic functioning: Cross-sectional and longitudinal observations in an inner-city school sample.
      ]. All four studies demonstrated significant improvement in one or more of the following: GPA, academic grades, or standardized test scores.
      The remaining five studies were cross-sectional and examined the relationship of hunger, insufficient food, or lack of adequate consumption of specific foods such as fruits, vegetables, or dairy products [
      • Alaimo K.
      • Olson C.M.
      • Frongillo E.A.
      Food insufficiency and American school-aged children's cognitive, academic, and psychosocial development.
      ,
      • Kleinman R.E.
      • Murphy J.M.
      • Little M.
      • et al.
      Hunger in children in the United States: Potential behavioral and emotional correlates.
      ,
      • MacLellan D.
      • Taylor J.
      • Wood K.
      Food intake and academic performance among adolescents.
      ,
      • Neumark-Sztainer D.
      • Story M.
      • Dixon L.B.
      • et al.
      Correlates of inadequate consumption of dairy products among adolescents.
      ,
      • Neumark-Sztainer D.
      • Story M.
      • Resnick M.D.
      • Blum R.W.
      Correlates of inadequate fruit and vegetable consumption among adolescents.
      ]. In all five studies, inadequate dietary intake was associated with at least one or more of the following: lower grades, lower standardized test scores, or increased likelihood of grade level retention.

      Discussion

      For all six health-risk behaviors identified to be leading causes of death, disability, and social problems among youth and adults in the U.S., 96.6% of the articles included in this review that were published in peer-reviewed journals from 1985 until the end of 2010 (a 25-year span) reported statistically significant inverse relationships between health-risk behaviors and academic achievement among school-aged populations. The results of the research reviewed are not evidence of cause and effect; the data do not indicate that poor grades cause health-risk behaviors, nor do they indicate that health-risk behaviors cause poor grades. However, the results support strong positive associations between six health-risk behaviors and poor academic achievement, and inverse associations between six health-risk behaviors and academic achievement.
      Longitudinal studies in this review provided information about the reciprocal effects of health-risk behaviors and academic achievement, and also identified health-risk behaviors that might be considered antecedent. Analysis of those results supported the hypothesis of Henry [
      • Henry K.L.
      Academic achievement and adolescent drug use: An examination of reciprocal effects and correlated growth trajectories.
      ], that the process of academic disengagement and drug use have reciprocal effects and patterns of growth trajectories during adolescence. Longitudinal studies in our review confirmed the description by Allison [
      • Allison K.R.
      Academic stream and tobacco, alcohol, and cannabis use among Ontario high school students.
      ] of the relationship between health-risk behaviors and low academic performance as “mutually reinforcing.”
      The results of this review are consistent with data from the 2009 National Youth Risk Behavior Survey that was reported in 2010. Students completing the national Youth Risk Behavior Survey were asked about academic grades mostly earned in school, and given seven response options: mostly As, mostly Bs, mostly Cs, mostly Ds, mostly Fs, none of these grades, or not sure. Those findings indicate a negative association between all six health-risk behaviors and academic achievement after controlling for sex, race/ethnicity, and grade level [

      U.S. Centers for Disease Control and Prevention. Unintentional injury and violence-related behaviors and academic achievement. Available at: http://www.cdc.gov/healthyyouth/health_and_academics/pdf/unintentional_injury_violence.pdf [accessed 06.08.11].

      ,

      U.S. Centers for Disease Control and Prevention. Tobacco use and academic achievement. Available at: http://www.cdc.gov/healthyyouth/health_and_academics/pdf/tobacco_use.pdf [accessed 06.08.11].

      ,

      U.S. Centers for Disease Control and Prevention. Alcohol and other drug use and academic achievement. Available at: http://www.cdc.gov/healthyyouth/health_and_academics/pdf/alcohol_other_drug.pdf [accessed 06.08.11].

      ,

      U. S. Centers for Disease Control and Prevention. Sexual risk behaviors and academic achievement. Available at: http://www.cdc.gov/healthyyouth/health_and_academics/pdf/sexual_risk_behaviors.pdf [accessed 06.08.11].

      ,

      U. S. Centers for Disease Control and Prevention. Physical inactivity and unhealthy dietary behaviors and academic achievement. Available at: http://www.cdc.gov/healthyyouth/health_and_academics/pdf/physical_inactivity_unhealthy_weight.pdf [accessed 06.08.11].

      ].
      The synthesis of the relationship of physical activity and academic achievement in this review is similar to the results of a more extensive review conducted by the CDC and published in 2010 [
      • U.S. Centers for Disease Control and Prevention
      The association between school based physical activity, including physical education, and academic performance.
      ]. However, the CDC review differed in that it included studies with a wider range of contexts for being physically active at schools, and included many studies conducted outside the U.S. and Canada because researchers included original research published in English, not limited to students in the U.S. and Canada. The results of the review confirmed that providing physical education classes as part of the instructional day do not reduce academic achievement, and being physically active at school is positively correlated with improved performance of specific cognitive tasks [
      • U.S. Centers for Disease Control and Prevention
      The association between school based physical activity, including physical education, and academic performance.
      ]. It is noteworthy that the inverse association between being physically active and academic achievement in the studies included in this review (71.4% for longitudinal studies and 66.7% for cross-sectional studies) was much lower than that reported for the other five behaviors (Table 2). This suggests that future research using variables of physical activity, both in and out of school, and academic achievement is needed to determine that interrelationship.
      Some of the research in this review included measures of academic achievement in addition to those required. The additional measures in the studies were school attendance, teacher-rated educational engagement, school involvement, academic stream in high school, high school class rank, on time/late high school graduation, and self-reported chances of attending and/or graduating from college (Table 2). Although we did not include those measures of academic achievement in the discussion of this review, some may be interesting to policy and program planners. For example, the effect of participation in school breakfast or lunch programs on school attendance was analyzed in three longitudinal studies ranging from 4 months to 10 years in length [
      • Kleinman R.E.
      • Hall S.
      • Green H.
      • et al.
      Diet, breakfast, and academic performance in children.
      ,
      • Meyers A.F.
      • Sampson A.E.
      • Weitzman M.
      • et al.
      School breakfast program and school performance.
      ,
      • Murphy J.M.
      • Pagano M.E.
      • Nachmani J.
      • et al.
      The relationship of school breakfast to psychosocial and academic functioning: Cross-sectional and longitudinal observations in an inner-city school sample.
      ]. All three studies reported not only significant improvement in grades and standardized test scores, but also fewer school absences.
      The results of this review suggest that improving health and increasing academic achievement of children and youth in the U.S. need to be viewed as a composite goal rather than separate goals that are responsibilities of different agencies. Furthermore, the results of this review suggest that the practice of providing programs that focus exclusively on school performance, health behavior, or health care need to be jointly evaluated by agencies responsible for children and youth.
      In 2010, Basch [
      • Basch C.E.
      Healthier students are better learners: A missing link in school reforms to close the achievement gap.
      ] coined the term “educationally relevant health disparities” in reporting the results of a meta-analysis of research about health and academic achievement. The health disparities he reported to be related to academic achievement were vision, asthma, teen pregnancy, aggression and violence, physical activity, breakfast, and inattention and hyperactivity. In like manner, the results of this review of 25 years of research affirm that health-risk behaviors and academic achievement are highly interrelated, which highlights the need and the potential of decision makers in agencies responsible for both education and health to work together in a less fragmented and more synergistic manner.
      Having information about groups of adolescents who are most vulnerable to both health-risk behaviors and academic failure can help in planning both prevention and intervention programs in the arenas of education and health. The results of this review support the assertion by Hawkins [
      • Hawkins J.D.
      Academic performance and school success: Sources and consequences.
      ] that the promotion of academic success in youth susceptible to health-risk behaviors may reduce the likelihood of them engaging in behaviors that threaten not only their health, but also their performance at school.
      The findings of this review highlight the importance of relevant public health objectives in Healthy People 2020 (http://www.healthypeople.gov), which are specifically about improving academic achievement. As stated in Healthy People 2020, those objectives are:
      These public health objectives about increasing high school graduation rates are forward-reaching acknowledgements that educational attainment is interrelated with health behaviors. The baselines and data sources for these objectives in Healthy People 2020 can be accessed at: http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx.

      Implications

      The results of this review of 25 years of research published in peer-reviewed journals provide clear evidence of the extent to which health-risk behaviors and academic achievement are interrelated and have long-term consequences for youth, adults, and society. These results could be used to inform coaction led by national leaders in health and education to address “educationally relevant health disparities” [
      • Basch C.E.
      Healthier students are better learners: A missing link in school reforms to close the achievement gap.
      ].
      In Healthy People 2020, there is an objective that would have reciprocal effects and could serve as the basis for the initial focus of interagency coaction:
      • Objective ECBP-2: Increase the proportion of elementary, middle, and senior high schools that provide comprehensive school health education to prevent health problems in the following areas: unintentional injury; violence; suicide; tobacco use and addiction; alcohol or other drug use, unintended pregnancy, HIV/AIDS, and STD infection; unhealthy dietary patterns; and inadequate physical activity [

        U.S. Department of Health and Human Services. Healthy People 2020. Available at: http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx [accessed 06.10.11].

        ].
      The baseline of 25.6% for objective ECBP-2 was provided by data from CDC's 2006 School Health Policies and Practices Study. The School Health Policies and Practices Study is a well-established system for collecting data from state departments of education and schools across the nation about the status of health programs in schools including school health education programs; the system has the capacity to track progress of mutual interagency (education and public health) goals and objectives [

      U.S. Centers for Disease Control and Prevention. SHPPS: School Health Policies and Practices Study. Available at: http://www.cdc.gov/HealthyYouth/shpps/index.htm [accessed 06.18.11].

      ]. School Health Policies and Practices Study data can be accessed at www.cdc.gov/HealthyYouth/shpps/index.htm. Another surveillance system, Youth Risk Behavior Surveillance System, was designed to track health-risk behaviors of school-age youth using data obtained from the Youth Risk Behavior Survey. The data can be accessed at www.cdc.gov/yrbs. Actions to improve school health education were addressed in the National Action Plan to Improve Health Literacy, which was created in 2010 by the U.S. Department of Health and Human Services [

      U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. National Action Plan to Improve Health Literacy. Available at: http://www.health.gov/communication/hlactionplan/pdf/Health_Literacy_Action_Plan.pdf [accessed 06.24.11].

      ]. Examples of action steps to improve health literacy through schools include:
      • Promote federal, state, and district policies to provide annual comprehensive school health education for all K–12 students
      • Promote federal, state, and county policies to provide health education in preschools and Early Head Start programs
      • Implement proven strategies to help all students graduate with a regular diploma in 4 years
      • Implement proven strategies to help all students develop proficient reading and math skills
      • Create a periodic assessment of and report on K–12 students' health literacy skills as defined in the National Health Education Standards [
        • Joint Committee on National Health Education Standards
        National Health Education Standards: achieving excellence.
        ].
      In addition to providing school-based and age-appropriate health education to reduce health-risk behaviors, other observable and measurable outcomes of interagency coaction supported by the results of this review are:
      • A comprehensive national interagency action plan with measurable outcomes
      • Dissemination of model polices that promote interagency coaction with incentives for agencies to implement the policies
      • Standards of practice for health care professionals who serve children and adolescents, including asking questions about academic achievement (such as grades and attendance) as a routine part of health histories.
      It is unlikely that the outcomes suggested could be realized without dedicated staff assigned to accomplish the coactions and placed in the lead agencies at national and state levels such as the U.S. Department of Education, U.S. Department of Health and Human Services, and the corresponding state-level departments in health and education or without a national steering committee composed of key stakeholders.
      The ideal long-range outcome of interagency coaction to address educationally relevant health disparities would be a unified system to improve educational outcomes and, at the same time, promote health-enhancing behaviors among school-aged youth. Addressing both health behavior and academic achievement in a unified system would have reciprocal and synergistic effects on the health not only of children and adolescents, but also of adults in the U.S. In 2003, a guide for those who work outside of schools and share the composite goal of improving both health and education outcomes for children and youth was created by an interdisciplinary team convened by the National Association of State Boards of Education [
      • Bogden J.F.
      How schools work and how to work with schools: a primer for professionals who work with children and youth.
      ].
      In May of 2012, Health in Mind, an initiative of the Healthy Schools Campaign and Trust for America's Health to improve education through wellness, presented actionable policy recommendations to the U.S. Secretary of Health and Human Services and the U.S. Secretary of Education. “These recommendations represent a major culture shift in how the nation views health and education—health and education will no longer be separated from one another …” (p. 1) [

      Healthy Schools Campaign and Trust for America's Health. Health in mind: improving education through wellness. Available at: http://www.healthinmind.org [accessed 12.17.12].

      ].
      In 1994, a committee of experts was convened by the Institute of Medicine of the National Academy of Sciences to address the health of students in U.S. That committee published the statement that students “should receive the health-related programs and services necessary for them to derive maximum benefit from their education and to enable them to become healthy, productive adults” (p. 14) [
      ]. The title chosen for the report of that committee was Schools and Health: Our Nation's Investment [
      ]. Because of persuasive evidence about the interrelationship of health-risk behaviors and academic achievement, it is imperative that leaders in education and health act together to make wise investments in our nation's school-aged youth that will be beneficial for the entire population.

      Acknowledgments

      Special acknowledgment and appreciation is given to Carolyn J. Fisher, Ed.D., CHES, FASHA who recently retired as the Senior Advisor for Coordinated School Health, Division of Adolescent and School Health, U.S. Centers for Disease Control and Prevention. Dr. Fisher played a very important role in the development and critique of this review article.
      This review would not have been possible without the guidance and help of the following U.S. Centers for Disease Control and Prevention staff members: Lisa Barrios, Dr.Ph., Nancy Brener, Ph.D., Sarah Lee, Ph.D., and Amy Schnall, M.P.H. Invaluable assistance was also provided by the Director of the Bureau of Health Promotion, Kansas Department of Health and Environment, Paula F. Clayton, M.S., R.D., and Rachelle Johnsson-Chiang, M.P.H., National Association of Chronic Disease Directors. This publication was developed under a cooperative agreement with the National Center for Chronic Disease Prevention and Health Promotion of the U.S. Centers for Disease Control and Prevention (Cooperative Agreement U58DP002759-01). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Association of Chronic Disease Directors or the Centers for Disease Control and Prevention.

      Supplementary Data

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        Journal of Adolescent HealthVol. 52Issue 6
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          Bradley BJ, Greene AC. Do Health and Education Agencies in the United States Share Responsibility for Academic Achievement and Health? A Review of 25 Years of Evidence About the Relationship of Adolescents' Academic Achievement and Health Behaviors. J Adolesc Health 2013;52:523–532. http://dx.doi.org/10.1016/j.jadohealth.2013.01.008 .
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