Consulting with Schools on Health Issues

C. PROVIDING CONSULTATION FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS

Pediatricians should always have input into the care of school children with special health care needs, particularly for those who are their patients.

1. Scope of the Problem

  • Approximately 10% of school children have special needs.
  • Nearly 40% of these children have learning disabilities, speech impairments, emotional disorders, or mental retardation.
  • Although fewer children are technology dependent, their number continues to grow with the trend toward inclusion.

2. Role of the Pediatrician

Pediatricians working in and with schools must ensure that the care provided to children with special health care needs is:

  • Family-centered
  • Community-based
  • Coordinated
  • Comprehensive
  • Culturally appropriate

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Pediatricians can undertake numerous strategies to ensure the proper care of the school children with special health care needs in their communities.

  • Share information with the school staff about the health care issues with specific children that may affect school planning. These might include treatments needed in school, how to manage emergencies, special restrictions on classroom activity or participation, and planning for physical education.
  • Share information-with parent's and child's consent-about the effect of the illness on a child's ability to learn.
  • Serve as resources for teachers and other school personnel on specific illnesses by providing understandable information about the illnesses, their consequences, and long-term expectations.
  • Join the parents in consulting with school staff on the importance of a welcoming and supportive environment for children with special needs.
  • Improve health education curricula about chronic illness and disability so that children can learn more about these issues and be more accepting of children and adults with long-term illnesses.
  • Become familiar with guidelines of the state teachers' union and the nurses' union on what teachers and what nurses can and should do in certain circumstances. A nurse can delegate certain duties to a teacher or aide.

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3. What a Child with Special Needs Requires

Pediatrician should ensure that every child with special needs in his or her practice has access to the following:

Screening and surveillance.

  • Pediatricians should screen all children on the first encounter, checking for risk of a handicapping condition or developmental delay.
  • Pediatricians are in key positions to identify at the earliest possible age the children who may benefit from services under IDEA.

Comprehensive assessments.

  • A child identified through screening or observation as being "at risk" for developmental delay should receive a comprehensive multidisciplinary assessment. The pediatrician plays an important role as a referral source or as a member of a multidisciplinary team.

Counsel and advice.

  • During the assessment process, families will need a knowledgeable source of medical advice and counsel. There should be a strong link between the assessment team and the primary care pediatrician.

Individual Education Plans (IEP) and Individual Family Service Plans (IFSP).

  • Pediatricians who participate in the assessment process should be consulted when IEPs and IFSPs are created.
  • Pediatricians who do not serve on the assessment team, should review the plan developed.
  • The pediatrician should determine whether the health-related services proposed are appropriate and sufficiently comprehensive.

Coordinated medical services.

  • When health services are part of the IEP or IFSP, the primary care pediatrician or an appropriate subspecialist should perform the services.
  • Services and communication should be coordinated when the patients have complex medical needs involving several physicians or health care centers.

Advocacy on behalf of children.

  • Pediatricians have many local and state opportunities to serve as knowledgeable and thoughtful advocates for children with special needs.

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4. The Individual Family Service Plan (IFSP)

The IFSP is a written plan to provide services to children from birth through age 2 years who have been identified as "at risk." The plan is based on the assessment by a multidisciplinary team and addresses the specific abilities and needs of the child and family.

The IFSP is developed through evaluation of the following 5 developmental domains:

  • Physical
  • Cognitive
  • Communication
  • Social or emotional
  • Adaptive

The IFSP should include statements on the following:

  • The child's present developmental status
  • Family strengths
  • How to enhance development of the handicapped infant or toddler with disabilities
  • Major outcomes expected, which should incorporate criteria, procedures, and timelines to achieve specific goals
  • Specific early intervention services that will help the child and family
  • Projected dates for initiating services and their duration
  • Name of the case manager responsible for helping the family implement and coordinate the plan
  • Steps to help the child and family with the transition to school services

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5. Developing the Individual Education Plan

The IEP is a written plan to provide services to children aged 3-21 years old who have been identified as "at risk," is based on the assessment of a multidisciplinary team. The following are ways that pediatricians can assist:

Identification and referral.

  • Pediatricians are one of the major professional groups who may identify children who could benefit from special education. The emphasis now is on early identification.

Evaluation.

  • Depending on the child's problem, different types of evaluation may be appropriate. In general, all children receive basic psychological testing, some form of family history taking, and then specialized evaluations regarding the presumed deficit or difficulty. An individualized health care plan is must be drawn up for each child receiving health care services at the school, and this plan must become part of the IEP.

Designation or labeling.

  • Based on the team's evaluation, in most states the child will be categorized as having one of the following: speech impairment, specific learning disability, emotional disturbance, mental retardation, visual impairment, deafness, or physical disability.
  • Pediatricians should be aware that such "labels" help define appropriate services but can also be restrictive and "pigeonhole" children into broad categories.

Placement and review.

  • Special education has placed a heavy emphasis on the normalization of educational placement for children with developmental disabilities and other conditions.
  • Placement options can include special schools, special classrooms within the regular school, and, occasionally, institutionalization.

Services and interventions.

  • Special education programs have received certain autonomy and often operate somewhat independently of the regular programs. The school health team may be asked to comment on the best package of services for an individual child, or the school physician may be asked to "order" and monitor these services.

Due process.

  • Parents have the right to agree or disagree with the educational plan established for their children.
  • Parents have the ability to call for a "second opinion" regarding the service plan.

6. Other Programs for Children with Special Health Care Needs

  • Children with chronic illnesses may also have special health care needs in the educational setting. Chronic illnesses are conditions that last at least 3 months or require extensive hospitalization or in-home services.
  • Chronic illnesses affect 10% to 15% of American children.
  • Chronic illnesses may include rheumatoid arthritis, asthma, leukemia, seizure disorders, neuromuscular diseases, or AIDS. There is also a small but increasing number of children dependent on specific technologies, such as ventilators.
  • The rights of children who do not meet the requirements for an IEP, but who require "related services" to remain in school, are protected under Section 504 of the Rehabilitation Act of 1973.

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7. Other Issues for Pediatricians

Medications in schools.

  • Schools need specific policies that address the proper storage and distribution of medications, including policies that will allow students capable of taking their own medications to do so when appropriate.

Emergency situations.

  • Each school should have policies and procedures for handling emergency situations with specific attention paid to children with long-term illnesses or disabilities.
  • Pediatricians, with the participation of the family, should develop individualized standing orders. These orders should be discussed with the school physician consultant or person responsible for health services. Teachers and staff should be instructed about the orders when the child enters school.

Homebound teaching and absence policies.

  • Pediatricians should be aware that homebound teaching has its limitations, and school attendance should be encouraged whenever possible.
  • Some communities and states have developed creative programs that identify children whose chronic illnesses are likely to lead to frequent, intermittent absences. These children then become eligible for homebound teaching without the usual waiting period.

Communication with school personnel.

  • Pediatricians can instruct the school staff about chronic illness, the specific health care requirements of children in their classes, and the provision of added resources to help prevent problems in the classroom.
  • Physicians should, with parental approval, share information about a specific child's illness with school staff so that staff can be better informed and able to help the child succeed.