OBJECTIVES

1. Describe the rarity of serious health care needs of children.
2. List and describe the most important considerations in disease prevention.
3. List the major types of medications used by children with disabilities and procedures for managing them in school.
4. List and describe the prevention and treatment of special care needs, including pressure sores, urinary tract infections, chronic pain management, ostomy and respiratory care, and orthopedic disabilities.
5. Describe concerns about special health needs, such as allergies, sinusitis, asthma, cystic fibrosis, diabetes, epilepsy, and cardiac disorders.
6. Describe best practices for physical management of children with health care needs.
7. List sources of health and related information.

Students with specialized health care needs will be so rare that the typical teacher will not encounter one in a career. For example, ventilator or tracheostomy dependence, oxygen dependence, severe congestive heart problems, apnea monitoring, and kidney dialysis are severe medical conditions unlikely to occur in a typical school. The teacher who will be confronted with the need to "suction mucous" or withhold resuscitation for a child in "cardiac arrest" probably has an equal chance of winning a lottery. The courts have already ruled that students whose lives may be at risk because they require a special setting near medical service, can be excluded, and they have ruled that students with special physical needs must have supplementary services available or the school will be in violation of the law. Therefore, the teacher would have support personnel.  This "worst case" scenario is a common propaganda technique.

The actual responsibility of the classroom teacher in such cases will ordinarily be very explicit because these children are well-known and have fully documented case histories, frequent medical examinations, and considerable support from medical personnel. Schools supervise or coordinate the administration of medication, perhaps monitor nutrition, and monitor respiratory management and other procedures for some children.

In any case of medical need, the underlying condition must be dealt with adequately in order for students to derive any benefit from instruction, because medical problems of a child will impact learning. Pain, fatigue, restricted mobility, medication, and various physical conditions can limit attention, motivation, and performance. Optimal learning depends, in part, on optimal medical treatment of underlying problems, which is also true for a broken arm, ear ache, or a chronic, debilitating disease. In such cases there must be some plan of action on behalf of the school to accommodate to the needs of the student in the classroom. In any case, this will never be the total responsibility of the classroom teacher.

In the past, students with extreme health needs were excluded from school or required such acute care they could not attend school. Also, some conditions often led to death so that school was not often considered a priority. Advances in medical treatment have greatly expanded the options for children with a variety of extreme medical conditions, enabling them to be able to attend school and to lead longer lives. Although requiring special safeguards, such students are sometimes placed in regular classrooms.

The responsibility of the classroom teacher includes a degree of care relating to monitoring, specific interventions, and adjusted classroom expectations. Careful assessment and an IEP can clearly identify what a child needs in order to succeed, and what the school must do to support learning. Medical complications must be taken into account in lesson plans and assignments. Students are likely to miss school due to medical conditions but they should not be penalized for it, and cooperative planning with the parents, medical personnel, and the school can limit the effects.

Although it is intimidating, teachers should not defer to the medical implications of a child's disability (Hobbs, Perrin, Ireys, Moynihan, & Shayne, 1984). Planning should account for routine interventions, medication and other medical interventions so that classrooms will not be interrupted.

Modifications of the curriculum and learning activities for students with health care and/or physical disabilities can proceed on the basis of individualized habilitation and management plans developed in cooperation with medical personnel. The school should have a plan for handling health-related problems and emergencies, and all personnel should be aware of the plan and receive appropriate training.

A plan should be developed for each student who has a known medical need, such as diabetes, allergy, asthma, and so forth, including precise instructions about medications, including location, storage, handling, and dosage, and measures to take in the event of an episode, such as seizure activity, use of a bronchodilator, and other steps. The plan might also include backup procedures for providing missed lessons and instructions, if students were unable to attend class due to illness or a medical episode. Communication between the school and home is critical.

Common Considerations

The school should have specific written policies concerning the administration of prescribed medicines by school personnel during school hours, such as the Valentine School in San Marino, California. For children it is critical that the prescribed dosage be very accurate and administered at the correct time. While school personnel may be able to administer the dosages properly using accurate devices (syringes, droppers, cups, pills, and capsules), sometimes a dosage may be missed. In this case, the school should know what to do. In some cases it may be necessary to wait until the next time, others may require a double dosage, and so forth.

Storage of medication should be included in the written policy. Medication must be kept in a locked, limited access space in either the office of a full-time registered school nurse or in the building administrator's office. If the there is no nurse, the school will have to have a person designated to handle the storage of medication. A school could be held liable under current laws if a child is denied access to school because there is no person qualified or willing to manage medication. A record of medication administration should be kept on file for each student receiving medication. The professional should be warned in writing of personal liability in the administration of medication. The professional has the right to refuse to administer medication if the school does not have clearly stated written policies that include the administration records and storage provisions, or if these policies are not strictly followed.

First Aid. As a practical matter, all school personnel should be well trained in first aid procedures. First aid for minor injuries are routine in most schools, and so are treatments for sudden allergic reactions. However, treatment for emergencies, such as bleeding and resuscitation are not routine in many schools. Ordinarily this might not be a concern, but anyone working with children who have health care problems should be prepared.

Pressure Sores.  Also called decubitus ulcers, pressure sores are caused by staying in one position for long periods of time due to immobility. The lack of circulation and contact with a surface and the effects of gravity cause a sore to develop. It starts as a reddened area, becomes hard, and can become ulcerated. To prevent sores, students in wheel chairs should have procedures and routines to follow each day. This may involve the use of pads, air cushions, and other devices, and repositioning.

Urinary Tract Infections.  Students who are not mobile or who have catheters can develop infections of the urinary tract. While medication will be used to treat the problem after its occurrence, prevention regimens involve frequent intake of fluids and special care in handling catheters.

Chronic Pain Management. Controlling pain can entail a regimen of exercise, diet, medication, and various electrical interference techniques intended to disrupt the pain signals (transcutaneous electrical nerve stimulation). While it is likely that children who have difficulty will make their discomfort known, teachers and other school personnel can be of assistance by noting the problems so that medical personnel can be informed.

Ostomy. A few children with health problems may have surgical procedures to permit bowel elimination through a surgically prepared opening (stoma) into a disposable bag (ostomy). While this probably will not involve school personnel, it is important for the school to be aware of such conditions and problems that may develop.

Respiratory Care. A child may have an opening in the throat (tracheostomy ) to enable easier breathing with an oxygen tank. A tube is inserted into the stoma. As a rule, students will have the tube inserted at home. On occasion, students may need to be removed from the classroom to have secretions removed and the tube cleaned and reinserted.

Orthopedic Disabilities. Mobility and access to classrooms are major concerns of students with orthopedic disabilities. Those who use braces, canes, crutches, wheelchairs, and/or prostheses may require more time than other students to move about the building. These students can also be tardy due to transportation complications, bad weather and waiting time for elevators. On occasion a prostheses or wheelchair can malfunction or breakdown, interfering with school. Typically only minor accommodations are necessary to meet the needs of students. In special rooms, such as science and computer labs, other arrangements may need to be made to assure that students can have good access to equipment.

Amputation. Due to birth defect, accident and disease, some children experience amputation of one or more limbs. The main problems relate to limited mobility or hand-function. Some children and adults with amputations will use wheelchairs, but more commonly attempts are made to devise various prosthetic devices for them to use to improve mobility and/or hand use. The needs of children are quite different than adults. Having once had an ability and losing it is quite different than not acquiring it during the developmental years. Thus, children with prosthetic devices must receive a lot of training and therapy, especially because the growing body requires frequent changes in prosthetics.

Arthritis. Arthritis affects approximately 37 million Americans, mostly adults. Arthritis causes joint inflammation, swollen tissues, and pain. In more serious cases, there can be deformity, loss of mobility, and damage to bone and tissue. Children who have arthritis may miss a lot of school. While in school, they may experience pain. They may not be able to participate in sports activities, nor may they well enough to attend fully to details of class work.

The typical treatment involves some form of pain management, including medication, physical conditioning, exercises, relaxation, and hot and cold treatments. The typical classroom teacher is unlikely to ever have a child with juvenile arthritis; if so, the responsibilities incumbent on the teacher will not be extraordinary.

Cerebral palsy. Cerebral palsy is caused by an injury to the brain before, during or soon after birth that results in disorders of posture or movement. There are different conditions that may affect children such as involuntary muscle movements, rigidity, spasticity, incoordination, and problems with balance. The diversity of characteristics requires a close estimation of each student in order to provide optimal educational support.

Associated with cerebral palsy may be poor spatial relations, visual, auditory, and speech problems, mental retardation, seizures, and problems of fine motor coordination. Due to motoric problems students may have frequent cuts and contusions. Some students may be subject to seizure activity.

Multiple Sclerosis.Multiple Sclerosis (MS) is a progressive disease of the central nervous system characterized by a decline of muscle control. Symptoms may range from mild to severe: blurred vision, legal blindness, tremors, weakness or numbness in limbs, unsteady gait, paralysis, slurred speech, attention, and depression. The onset of the disease usually occurs between the ages of 20 and 40, so most public schools do not have many students with MS.

Sickle Cell Anemia. Sickle cell disease is a genetic disorder of the red blood cells in which the hemoglobin molecule is abnormal having the appearance of a sickle shape. These cells circulate poorly causing anemia, tissue oxygen starvation, and considerable pain. Reduction of blood organs and depletion of oxygen can result in other complications such as disease of the eye, cardiac disorders, problems with limbs and joints, lung problems and abdominal pain. Students may miss school for long periods.

Spina Bifida. Spina bifida is caused by a birth defect of the central nervous system occurring during the first month of pregnancy because the neural tube fails to close. The spinal cord may extrude. The location of the defect will determine the type of disorder and extent of impairment. The higher the defect is on the spinal cord and the amount of extruding spinal cord and/or tissue and fluid determines the severity of impairment. Children may have paralysis, urological, and associated orthopedic and neurological problems. Due to paralysis, there needs to be attention to cuts and other injuries that may not be noticed by the student. Children with spinal bifida have routinely attended school without serious complications.

Muscular Dystrophy. Muscular dystrophy (MD) refers to a group of hereditary, progressive disorders with onset in young people. MD results in a degeneration of voluntary muscles of the trunk and lower extremities. The most common form is Duchenne which is onset early in life, therefore it is the type most frequently seen in schools. Muscle atrophy results in weakness, fatigue, and leads to respiratory or cardiac problems. In class the student will have difficulty manipulating materials and ambulating around school.

Hip Disorders. Children who have various hip disorders will have difficulty with mobility and experience discomfort sitting in one position or in an upright position for long periods of time, such as in a classroom. Most often they are provided with special chairs that tilt in space--called orientation in space systems, rotational seating systems, or fixed hip recliners. The chairs allow the user to tilt back without changing back angle, rather than reclining the back of the chair while retaining the seat in a horizontal plane. Many kinds of chairs have been developed because of the large older population and the technology is available for children, including strollers, travel chairs, and wheelchairs. Tilting chairs may also be used for some children with cerebral palsy, brain damage, and multiple sclerosis. Like other considerations in this category, an evaluation will be made by a group of health professionals and the teacher will have no responsibility for making decisions about it.

Osteogenesis Imperfecta.Osteogenesis Imperfecta is a genetic disorder characterized by "brittle" bones or bones that break easily and is caused by the mutation of a specific gene. Some individuals have only a few broken bones but others may experience dozens of fractures over a lifetime. The collagen fibers that reinforce bones are defective which causes weakened bone structure. The incidence is quite low with about 1 birth in 20,000 to 30,000 presenting the condition at birth. While there are many treatments, such as nutrition, exercise, and surgical interventions, there is no cure. Other than concern about the child's welfare in an active school environment, there are no special considerations that fall to the teacher. An associated problem of hearing loss may occur if the bones in the middle ear are deformed.

Some of these students may attend public schools, although many attend specialized schools or are homebound. According to Sirvis, considerations for this population of students include:

• An hygienic but not sterile classroom.
• Flexible schedules to allow for limitations related to fatigue and mobility.
• Adaptation for academics and cooperative programs with home and hospital teachers.
• Avoidance of putting too much emphasis on medical implications.
• Planning for interruptions for medication or other medical interventions.

Children can be treated with antihistamines and desensitization (nasal steroid therapy). Perhaps one of the greatest problems for children, other than feeling tired and generally unwell, is that sinusitis and middle ear infection (otitis) are commonly associated with allergic reactions. This can mean that children cannot hear as well as normally. Treatment in the classroom may include preferential seating and amplification of sound (not common but effective).

Sinusitis.  Sinusitis is one of the leading chronic medical conditions is increasing in prevalence. It is very common in children, with varying kinds of nasal discharge, coughing, headache, and facial pain. The condition is treated with antibiotics, nasal decongestants, antihistamines, and desensitization therapy (Wald, 1992).

Asthma. Many students have chronic breathing problems, the most common of which is bronchial asthma. Respiratory problems are characterized by attacks of shortness of breath and difficulty in breathing, sometimes triggered by stress, either physical or emotional. Fatigue, difficulty climbing stairs, problems with exercise, and other problems may ensue, including absence from school. Asthma is the most common pediatric lung disorder. Some estimates put asthma in children as high as 5% of children under the age of 15 years. Children with asthma experience swollen, irritated airways that cause periodic episodes when breathing is difficult or very labored. Major improvements been made in the treatment of asthma in recent years.

Teachers should be aware of "asthma triggers " that vary from one child to another. A trigger causes an attack. Triggers may include allergens, smoke, gaseous fumes, exercise, and emotional affect. These do not cause asthma, they trigger the symptoms to occur.

Children with asthma are usually taught to monitor themselves and their breathing, which can be done with a peak flow meter--a device that measures air flow. This can predict the onset of a potential asthmatic episode before the child is aware of it. Indications include tightness of the chest, coughing, wheezing, and shortness of breath.

Medications include bronchodilators and anti-inflammatory substances. Inhalers (dilators) quickly cause relaxation of the musculature around the airways. Anti-inflammatory medications reduce inflammation. Parents and the school personnel should develop a plan for treatment, which may include peak flow monitoring, procedures to follow in case of an episode or potential episode, and emergency procedures and referrals for emergency care.

Alcohol Syndromes. Alcohol abuse by pregnant women can result in unfortunate consequences for their children. A congenital condition caused by damage in fetal development due to the mother's intake of alcohol is known as fetal alcohol syndrome. Fetal alcohol syndrome has a myriad of distinctive physical characteristics such as narrow eye openings, an elongated midface, and thin upper lip. Children born with this condition are inclined to have learning and behavioral problems manifested as motor dysfunction, attention deficient disorder, hyperactivity, and sleep disorders. They may also have hearing defects and neurological abnormalities. Some children do not exhibit enough characteristics to be labeled fetal alcohol syndrome but are labeled fetal alcohol effect.

Prenatal Drug Exposure. An increasing number of children are being born who were prenatally exposed to drugs. Women who use drugs during pregnancy rarely do so in isolation. For example, illegal substances such as cocaine and marijuana are typically combined with cigarettes and/or alcohol, and these patterns of drug use make it difficult to determine the extent, duration, and/or the direct or combined ramifications of a specific type(s) of substance on development (Kronstadt, 1991). Chasnoff, Landress, and Barrett (1990) have estimated that 14% of women use alcohol or some type of drug(s) during pregnancy, and that these patterns of substance abuse cross all socioeconomic boundaries. Unlike the relatively consistent findings regarding the potential impact of alcohol on the fetus during the developmental period, isolating the specific and unique impact of other commonly used illicit drugs has proven to be difficult. No drug-specific syndrome or distinct developmental profile correlated with illicit substance exposure has been identified.

The U.S. General Accounting Office (1990) reported that between 42-52% of children prenatally exposed to drugs will require special education. This report also found that 25% of children prenatally exposed to drugs exhibit some type of developmental delay, and that 40% experienced neurologic dysfunction that may affect their ability to function socially in the classroom setting. Knowledge about short- and long-term effects on infants exposed to crack-cocaine is only beginning to emerge. Most children of substance exposure have typical intellectual abilities but less ability to modulate and control their own behavior and less task persistence than unexposed peers (Griffith, 1988). Observations by many researchers (Griffith, 1988; Tyler, 1992; Wright, 1994) include possible central nervous system damage which may cause learning problems as the child matures.

Cystic Fibrosis. Cystic Fibrosis is a disease caused by an inherited genetic defect and it is the most common genetic disease in the United States. Still, it is quite rare. The most debilitating effect is long-term deterioration of the lungs as a result of inability to clear the lungs of excessive mucus.

Diabetes. This s a chronic disease in which insulin, a hormone produced by the pancreas, is not produced normally to metabolize glucose in the body. Glucose builds up in the bloodstream. The goal of treatment is to keep blood sugar levels and in a normal range. There are two types of diabetes. Type I is known as insulin-dependent or Juvenile Diabetes because it occurs in children. In Type I diabetes, the pancreas produces very little or no insulin at all. Children must have one or more injections of insulin daily to keep metabolism normal. Actually, however, there is a balancing act between food, exercise, and insulin. Food ingestion increases glucose, exercise and insulin reduce glucose. If balance is not maintained, low blood sugar (hypoglycemia) or high blood sugar (hyperglycemia) can result. In either condition, children will be ill, unable to function properly, and under some circumstances may need to be hospitalized to maintain control.

Treatment of children with diabetes includes insulin injections, diet control, and a routine of exercise. Insulin injections are a daily routine. Children with diabetes usually adjust well and can take care of their own injections. For the therapy to be effective, food intake must be regulated. Exercises is the third aspect of treatment. Physical activity reduces the amount of sugar in the body.

The warning signs of an episode include irritability, sudden onset of hunger, excessive perspiration, dizziness, inability to concentrate, and trembling. The required intervention is immediate increase of sugar in the body. This is accomplished if the child eats a sugar cube, candy, or raisins and juice. Symptoms will usually disappear within a few minutes after a snack. Another danger is too little insulin, which may result from the child abandoning the routines of exercise, eating, and insulin adjustment. This is often a problem for adolescents, especially girls.

Epilepsy and Seizures.Seizures are characterized by abnormal electrical activity in the brain, caused by hereditary factors, disease, or injury. Episodes can involve loss of consciousness, twitching movements of the body, and hallucinations. The type of seizure is determined by the part of the brain where the activity occurs, which also result in different kinds of symptoms. According to the Epilepsy Foundation of America, seizures have been classified in several ways with different kinds of terminology, and with as many as thirty kinds of seizures recognized. Seizures are categorized as partial and generalized, and subdivided into the following types: simple partial, complex-partial, absence, tonic-clonic, and others. Numerous medications are used to treat seizure activity (Levy, Mattson, & Meldrum, 1995).

If it is determined that electrical discharge is restricted to one specific brain location, the seizure is partial. While there may be a variety of sensations, such as jerky movements, distortions in hearing or vision, or abdominal discomfort, consciousness is not impaired. By contrast complex-partial seizures involve both motor movements and impaired consciousness. During the seizure the patient appears dazed and confused.

The preferred term for what has been called petit mal seizure activity is absence seizure, common in children and disappearing during the teen years, in which there are lapses of consciousness lasting up to 15 seconds. The child may have the appearance of staring. If the child has frequent seizures, school performance can be adversely affected.

Tonic-clonic seizures, also known as grand mal, is the most dramatic in appearance. The subject experiences a loss of consciousness. The body becomes rigid, followed by jerking and twitching movements of the body. This type of seizure will require attention of a teacher. The common steps are:

• Push away objects that might cause injury.
• Assist the student to the floor.
• Turn the head to one side.
• Do not restrain the body or put anything in the mouth.
• Contact the school nurse or other responsible person if a school nurse is unavailable.

The responsibility and actions of school personnel are usually well documented by medical authorities. Children will usually have shortness of breath, limited exercise tolerance, cyanosis, fainting spells, and chest pain. They must be monitored carefully in play and exercise.

Lifting and Transferring

Some students are unable to transfer themselves from a wheelchair to a chair or toilet. They need assistance at such times, and this should be carefully addressed in the IEP or other health care plan of the student.

Safety is a major consideration with wheelchairs. Students in wheelchairs can cause injury to others and to themselves without some precautions. In ordinary use, the brakes should be applied when the student is transferring from the wheelchair to the desk or toilet. There needs to be some form of traffic control, if more than one wheelchair is in the room. Wheelchairs, like cars, should stay on the "right side of the road" when moving down hallways. Before turning or backing up, the student or person pushing a wheelchair should look first. The wheels should be locked when the chair is stationary. Since even small objects on the floor easily stop chairs, floors should be free form clutter and objects, a difficult task in some classrooms.
 

Toileting. For most children, toilet trainingoccurs easily and naturally. Becoming interested in toileting is a step in developmental autonomy. The basic physical requirement is ability to control muscles used for elimination, which usually occurs during the second year of life. Bowel control is usually established between 3 and 5 years of age. By age 5, most children are trained. Children quickly realize they can control urine and feces, and this promotes interest in bathroom routines. With the exception of bed wetting, many children are quickly "trained" and have few accidents.

Eating. Most children with disabilities have no problems feeding themselves, but some will need assistance due to physical limitations. In these cases, a plan should be developed for feeding assistance using classroom aides.

Dressing/Grooming. Being in the same classrooms with their peers, children with disabilities are able to imitate and model the behaviors, manners, and appearance of others. As any parent knows, this is not always desirable, depending on what is in vogue. In any event, dressing and grooming should not be of any particular concern unless certain students are noticed to have special problems. In these cases, the IEP should include some plan for teaching these skills.
 

Stretching activities should be designed to stretch the tendons, ligaments and muscles while preparing for exercise. This is followed by warm-up activities designed to gradually intensify. For any student with the health clearance, the goal is to reach aerobic or near-aerobic pulse rates. There should be a series of cool-down activities to prepare for the recovery phase. This is followed by relaxation training activities which are included so participants learn how to eliminate residual muscle tension. Using the carotid pulse, most students can learn for monitor themselves and their adjustment to exercise.

On a case-by-case basis, there may be specific kinds of exercises prescribed by physicians, occupational and physical therapists, and other professionals designed to increase muscle strength and endurance and promote flexibility of joints. This may involve extensions, stretches, twists, reaches and range of motion. There may be a concentration on upper body exercises done from a wheelchair, chair or standing table. These may be prescriptions of short duration, however. Students need to plan for life-long exercise programs.

Innovations in technology are making fitness accessible to the disabled. Mono-skis, bi-skis, sports chairs, wheel chairs, bicycles, hand-cycles, row-cycles, and tandem cycles are made of lightweight aluminum and other materials. People can get significant cardiovascular benefits from aerobic activity (Krucoff, 1991). ADA mandates equal access to recreational facilities, so there is development of new devices to engage persons with disabilities.

Without proper exercise and diet, and depending on the condition, as children grow older they can develop problems such as changes in skin, muscles and bones, lungs, heart, urinary system, gastrointestinal, nervous system, and immune system. Proper exercise can help prevent these conditions and reduce pain.

There are athletic events and serious competition for many persons with disabilities, such as wheelchair sports and recreation. Visits or videos of persons with various disabilities engaged in sports and recreation can be quite inspirational. There are many examples: ski and race activities like alpine (downhill) and Nordic (cross country) skiing; archery, basketball, canoeing, cycling, kayaking, lawn bowling, sailing, shooting, swimming, table tennis, track and field, volleyball, water skiing, and weight lifting.

The concept of inclusion needs to extend to the integration of students in recreational and leisure activities with age mates who do not have disabilities. Typically this requires an attractive activity of some sort, such as board games that naturally draw children together. The school can plan appropriate activities at home but community activities are much more difficult to organize, such as a swimming outing or a party.
 

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