SUMMER 2018
Dedicated to the Health of Arizona Children
PEDIATRIC DIGEST
School Health: The Role of Pediatric Professionals in Schools Pediatric professionals play an important role in helping school-aged children and adolescents reach their academic potential in a safe and healthy school environment
A LOOK INSIDE Special Feature on Preschool Expulsion -page 8
12
The Pediatrician’s Role in School Safety
14
The ABCs of Concussion Management
24
The Individuals with Disabilities Act (IDEA)
AzAAP President’s Report
W
e have dedicated this issue of the Pediatric Digest to the topic of the role of pediatricians in school health. The American Academy of Pediatrics has a Council on School Health (COSH) that defines school health as “an integration of wellness, safety, growth, learning, and development in the lives of school-aged children and
adolescents within the context of their school, and with the coordinated alliance of the family and the medical home.”
1
A few Arizona school health statistics to help us understand the challenges we face 2:
John Pope’s
President’s REPORT
17% of children do not graduate on time 17% of children have one or more emotional, behavioral, or developmental problems 20% of children have special health care needs Many more children have problems with reading or math
The COSH achieve their mission as a council by providing advocacy, technical assistance, education, and policy development in many areas such as school nursing, coordinated school models for health, prevention of learning and health problems through early detection and intervention, meeting the needs of children with special health care needs, and providing school based medical homes for children who lack access to a
Dr. Pope is AzAAP’s President and has
private medical home.
served on the Board of Directors for the past 6 years, as well as been involved on several committees and task forces. He is the Chief Medical Officer for the HonorHealth
In this issue, we will hear from pediatricians and other professionals across the state about their experiences in Arizona with helpful information about how we can help children in our practices who face health and learning problems as they integrate into school.
Scottsdale Shea Medical Center. Dr. Gary Auxier will share his experiences working in a school based clinic in Chandler, AZ. We will have a review of return to play after concussion from board member and state expert Dr. Kristina Wilson. We will also hear from ADHS and a local non-profit (Raising Special Kids) about how to support children with special health care needs as they enter school. Drs. Harold Magalnick and Sydney Rice and others will give us the ins and outs of eligibility for services, school accommodations, and laws that support us in advocating for services for children with health or learning problems.
Through this issue we hope to provide information for our members to educate, advocate, and influence policy for their patients and families with a goal to improve the health and well-being of children which is key to success in school and life. Sincerely,
John A. Pope, MD, MPH, FAAP AzAAP President
References: 1.https://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Council-on-School-Health/Pages/About-Us.aspx 2.www.datacenter.kidscount.org
Pediatric Digest, Summer 2018 Page 2
Supporting Pediatric Professionals is Critical to Improving Child Health
In this Issue:
ANNE STAFFORD, MA | AZAAP EXECUTIVE DIRECTOR AzAAP has the dual mission of improving the health of Arizona children and supporting the pediatric professionals who care for them. Because of our dedication to our mission and our members, we identified our priorities for Arizona children as well as our priorities for supporting our members in our Agenda for Children. At AzAAP, we know that providing our members with the support they need is critical to the success of Arizona children. With that in mind, our three priority areas for supporting members are Continuing Education, Member Support and Community, and Advocacy for the practice of pediatrics.
CONTINUING EDUCATION AzAAP has expanded our dedication to providing our members with quality education opportunities. Through a series of quality improvement projects, we are not only addressing learning opportunities to help improve health outcomes for your patients,
Anne Stafford, MA, AzAAP Executive Director
we are also providing the support you need to participate in these projects. To combat the cost burden of the Maintenance of Certification process, many of our quality improvement projects offer free MOC credit as well as a practice stipend. The practice stipends can be used to cover any additional staff time used during the project, incentives for your staff to acknowledge their commitment to improving health outcomes, or as additional income for your practice or providers. We’ve also expanded the number of CME credits at our Pediatrics in the Red Rocks conference and added the addition of MOC Part 2 credit. These additions confirm that you are getting the best return on your investment by choosing our education conference, while also enjoying the beauty and rejuvenation of the Sedona red rocks. As we know not all of our members cannot attend the Sedona conference, we are adding varied education choices for our members. Members can look forward to additional opportunities both online and in-person across the state in the coming year. Through ongoing and shared learning experiences, with opportunities to learn from local and national experts, we aim to meet all of your learning needs and be your professional home you turn to for all of your CME, MOC, and quality improvement needs.
MEMBER SUPPORT, COMMUNITY, AND ADVOCACY While AzAAP engages in many advocacy efforts regarding child health, the advocacy we do for the profession of pediatrics and your ability to meet the needs of your patients cannot be undervalued. Through the collective power of our Advocacy Committee, our lobbyist, and our staff, we have advocated for the preservation of the Sunrise Proposal process to protect the scope of practice of pediatric professionals and ensure that children are receiving care from properly trained professionals. We have also reinstated our Pediatric Council. The Pediatric Council works to educate health plans and managed care representatives about child health and issues of importance to the practice of pediatrics including concerns with plan policies, covered services and administrative hassles including advocacy for more appropriate coverage for pediatric services and claims adjudication. We will continue to work to address issues facing our members including working with schools. AzAAP is currently addressing the Governor’s School Safety Plan using evidence-based recommendations to encourage a more comprehensive and effective approach to reduce gun violence and protect children and youth in our schools and communities. As AzAAP grows and
page 4 Working With Schools: Notes From a Developmental Pediatrician page 6 A Pediatrician’s Role in Developing a School Service Plan page 7 Billing Corner—Care Plan Oversight Codes for Time Spent Working With Schools page 8 Preschool Expulsion: The Promise of Preschool and How Arizona Children are Missing Out page 10 The Role of Healthcare Professionals in Stopping Bullying page 11 Protecting Youth From Bullying: A Providers Prospective page 12 The Pediatrician’s Role in School Safety page 14 The ABCs of Concussion Management page 17 From ADHS: The Role of Healthcare Professionals Working with Schools page 19 Stock Inhalers for Schools: New Legislation in the State of Arizona page 21 Preparing for Your Future: Vaccinate Before You Graduate page 22 What Does “Eligible” for Special Education Mean? An Explanation From the School Setting page 24 The Individuals with Disabilities Act (IDEA) page 26 Special Education and Related Services page 27 Member Spotlight/Editor’s Note
adapts to meet the needs of our members and the children of Arizona, we are always looking for input and volunteers for our committees. Please reach out to get involved at leadership@azaap.org. Pediatric Digest, Summer 2018 Page 3
these diagnoses, but the school system is independent of the medical system in deciding IEP eligibility.
Autism Deaf-Blindness Deafness Emotional Disturbance Hearing impairment Intellectual Disability Multiple Disabilities Orthopedic impairment Other Health Impairment Specific Learning Disability Speech or Language Impairment Traumatic Brain Injury Visual Impairment Developmental Delay (preschool)
Educational professionals will review the documentation and
Working With Schools:
decide whether further testing is needed within the school
Notes From a Developmental Pediatrician
educational intervention. The educational professionals use the
BY SYDNEY RICE, MD, MSc | TUCSON, AZ
system or if the medical documentation is sufficient to begin an
information that is provided, but they may choose to do another evaluation to confirm a diagnosis or flesh out a child’s profile of
Children spend much of their waking lives in
abilities to be able to provide appropriate educational services. It
school. We all have fond and possibly painful
is most helpful to provide full documentation of the condition
memories of our time in the classroom and on the
rather than a brief note or prescription that states a diagnosis.
playground. How can we help children to receive
This may mean sharing notes from other providers and will
the support and education to make the most of
require that the family sign a release of information so that you
their time in school?
can share records. Without adequate documentation, the school staff will need to reach out for further medical documentation or
Children can receive educational support under two different
will need to complete a full reevaluation in the school system.
laws, the Individuals with Disabilities Education Act and the
One of the most flexible IEP designations from a medical
Rehabilitation Act. Physicians cannot mandate what occurs in the
viewpoint is the “Other Health Impairment” category. This
school system, but we can provide supporting medical
educational category can be used to support children with varied
documentation that will qualify a child for the appropriate
medical conditions including severe asthma, cancer, epilepsy,
support. Most school settings welcome input from a physician to
sickle cell disease, cardiac conditions or chronic bowel conditions.
help provide greater context to the child’s situation and plan for
Children who have ADHD may also be eligible for an IEP under
support and intervention.
the OHI category if there is enough documentation of how the condition affects a child’s health.
Individualized Education Plan (IEP) 504 Plan Children can receive educational support and accommodations if they qualify in the school system with a specific diagnosis under
Children can receive academic accommodations under a 504 Plan
the Individuals with Disabilities Education Act (IDEA). A child
if they have a medical condition that affects their learning. The
must have one of 14 diagnoses to qualify for an IEP. Medical
Rehabilitation Act of 1973, a law that was designed to prevent
professionals can provide documentation to support some of
discrimination for individuals with disabilities, governs the development and implementation of a 504 Plan. A 504 Plan is
Pediatric Digest, Summer 2018 Page 4
more flexible than an IEP, but it provides
sincere medical opinion regarding the needs of
less intense intervention. A 504 Plan allows
each child.
for academic accommodations, but does
References
not typically allow for interventions that require increased resources or direct interventions such as therapy or resource
FOR CLINCIANS: The American Academy of
classroom support. Typical accommodations
Pediatrics ADHD and Autism Toolkits provide
include preferential seating, decreased
sample letters for an IEP and a 504 Plan. Visit
homework load, a quiet location for testing
http://www.aap.org/autism and https://
and extra time for testing. Typical
shop.aap.org/Caring-for-Children-with-ADHD-A-
diagnoses that would merit a 504 Plan
Resource-Toolkit-for-Clinicians/.
include ADHD, traumatic brain injury or FOR PARENTS: The American Academy of
accommodations for a medical condition Sydney Rice, MD, MSc, FAAP,
that may resolve or improve markedly over the school year. For example,
Pediatrics http://www.healthychildren.org website
Developmental Pediatrics, Associate
provides parents with information and resources
Professor of Pediatrics,
for how schools can help children with ADHD and
children who have had a concussion may benefit from academic accommodations
University of Arizona, Tucson
autism.
for a few months, but they will likely return to their previous level of performance.
Questions
Communicating with the School
Dr. Sydney Rice can be reached by phone at the University of Arizona Genetics and Developmental
In general, school systems require that a child’s family initiate
Pediatrics Division Administrative Office: 520-626-
the communication with the school staff. The family may choose
6615.
to support your documentation with their request for evaluation and assistance or they may ask you to send records that will support their request. Contact is best performed by written communication to document dates of initiation and interaction. Families are frequently intimidated by the idea of initiating this contact and we can help support them by providing sample letters requesting evaluation. The American Academy of Pediatrics has letter templates that the family can use to submit their request and your office can help by providing the supporting documentation.
Summary Primary care providers have an opportunity to partner with school systems to make sure that they have the appropriate medical information to shape a child’s educational plan. The medical and educational systems have very different perspectives and function under different rules. We can best advocate for families in schools by providing accurate and complete records that document our
A Pediatrician’s Role in Developing a School Service Plan HAROLD MAGALNICK, MD, FAAP | PHOENIX, AZ I have been a general
“I have had the
pediatrician in the valley for
privilege of
almost 40 years. I have been
attending IEP
involved with schools for almost the entire time. My involvement
meetings for some
started when I was invited to Atlanta to become one of our
of the children in my practice from
state’s trainers for Public Law
preschool through
94-142 the Education for All
high school. Being a constant
Handicapped Children Act.
November 1975 and
emotionally disturbed, orthopedically impaired or other health impaired (OHI).
The 0-3 program is serviced through the Division of Developmental Disability (DDD) through the Department of Economic
participant has allowed me to
The law was passed in
handicapped, seriously
follow the child’s
Security (DES) while the older children are serviced through the Department of
implemented in October of
educational and
1977. In 1983, the law was
developmental
amended to allow states to
progress in ways
service providers, but a
apply for grants to provide
that would not be
transition plan has to be
services to disabled children
possible by just
aged 0-3. Under this law,
seeing them in my
handicapped children are
office.“
defined as those who have intellectual disabilities, formally
Harold Magalnick, MD, FAAP, General Pediatrician, Pediatrix at Black Canyon, Phoenix, AZ
to make sure that the child continues to require Special Educational services, but every year an Individual Educational Plan (IEP) must be developed in order to outline exactly what services are needed and what outcomes are expected.
Education (DOE). Each program has its grouping of
established when the child ages out of 1 group and must enter another. Each program must complete an evaluation to decide that a child is
classified as mental retarded (MR), hard of
appropriate for the program. This
hearing, deaf, speech impaired, visually
evaluation must be repeated every 3 years
If during the year these outcomes are not being realized, a revision of that plan can be done. Parents are required to be part of this process and actually have to sign off on the plan. During the evaluation and plan development process the family has to confront the full force of the educational team. That team can include teachers, therapists, school psychologist, school nurse and district administrators.* This can be quite intimidating for the family. To know what is educationally required for the child from what is medically needed can be daunting.
The school has the responsibility to pay for all the services that the child receives at school. They can apply for payment through the federal government, but the child’s individual insurance is not charged. This can be very important for families that are paying for services or have finite limits on services provided by their insurance.
Pediatric Digest, Summer 2018 Page 6
The presence of their pediatrician at the
compensation is small in
*In smaller communities, one person can play
table allows the families to feel that they
comparison to the family’s
multiple roles in an IEP meeting. Advocates can
have an advocate at the table that knows
gratitude and that is the true
be especially important here.
their child well and can articulate their
essence of the Medical Home
child’s needs. I have had the privilege of
being achieved.
attending IEP meetings for some of the children in my practice from preschool through high school. Being a constant
Billing Corner
participant has allowed me to follow the child’s educational and developmental progress in ways that would not be possible by just seeing them in my office. It has also
Care Plan Oversight Codes:
99339 (15-29 minutes) 99340 (greater than 30 minutes)
allowed the school’s team to get to know me so that they are more comfortable in calling me when issues arise.
Compensation Charging for this service is done
by writing a note in the child’s chart outlining what occurred at
Care Plan Oversight Codes can be submitted once each month on an individual patient.
The codes can help cover the expenses of time spent reviewing records (including educational records), calling-in or attending IEP meetings in person, or any care coordination provided by the provider during the month. Please visit the American Academy of Pediatrics website for more information about these billing codes.
the meeting, my input and the plans developed from the meeting.
https://www.aap.org/en-us/professional-resources/practice-transformation/getting
I charge it as if the consultation
-paid/Coding-at-the-AAP/Pages/Coding-and-Payment.aspx
was in my office. The monetary
*Billing corner codes and tips provided by the Pediatric Digest Editor, Dr. Cody Conklin-Aguilera
Preschool Expulsion: The Promise of Preschool and How Arizona Children Are Missing Out ALISON STEIER, PhD | PHOENIX, AZ The promise of high-quality preschool goes well beyond learning colors, letters, numbers and how to cut with scissors. It represents a protected release—often the first release—for young children into the world outside the nuclear family, a gentle entry into more possibilities.
Children in such a preschool environment have the opportunity to learn a great deal about themselves and the social world: How do you make a friend? How do you manage big feelings? How do you wait your turn? Listen well? Cooperate? Speak up? Dare to try new things? These are the very skills that kindergarten teachers tell us Alison Steier, Ph.D.,
they are thinking of when they talk about “school readiness.”
Director of Mental Health Services, Southwest Human Development
When children’s experiences are mediated by the skillful staff of a preschool, they learn what it means to be a member of a community, to have a feeling of “belonging.” They are welcomed in the morning, bid farewell at the
end of the day and missed when absent. They are “seen,” understood and supported, even when their preschooler passions erupt in a whack to a peer or the destruction of a friend’s carefully constructed block tower, because the adults in this setting appreciate early childhood as a time that is by definition for making mistakes and for learning their society’s ropes.
This description of high-quality early care and education may seem like a tall promise, but in fact it is proportional to the unique needs and opportunities that early development presents. Early development proceeds with a rapidity that is unparalleled in the rest of the life span and, of course, it is not reserved only for the time that children are with their parents. Thus, early care and education providers are important promoters of and influences on children’s development.
For children who have had or are having early beginnings that provide sufficient security, support and stimulation, highquality child care will echo and underscore their positive experiences at home. For children with difficult beginnings marked, perhaps, by loss, family disruption or trauma, highquality child care offers positive possibilities to counter, or at least compete with, the pessimistic stance that negative life events or circumstances tend to encourage.
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There is a catch. Those children who will not benefit cognitively, socially or emotionally are those in low-quality settings that do not meet their needs and those who are
Scottsdale | 480-538-2972 www.busolagroup.com
expelled from their program altogether.
National data indicate that suspensions and expulsions from early care and education settings, as disciplinary measures for challenging child behavior, are alarmingly common. Young children in pre-K programs are expelled at three times the rate of children in kindergarten through 12th grade. For child care programs, the rate of expulsion is 13 times the rate for K-12. Research further indicates that there are significant racial and
gender disparities in the
Research has shown that suspension and expulsion rates
practices of suspensions
decline when child care providers and teachers have
and expulsions, with young
access to mental health consultation and expertise
boys of color being expelled
around managing challenging child behavior.
much more frequently than other children.
Arizona is addressing the problem of pre-K suspensions and expulsions in a number of ways:
These findings, first published in 2005 by Dr.
Birth to Five Helpline: Arizona’s only free helpline for parents,
Walter Gilliam at the Yale
caregivers and professionals with questions or concerns about
University Child Study
children ages birth to 5. Topics include sleep, child
Center and later replicated in 2014 by the U.S. Department of Education’s Office for
development, fussiness/colic, challenging behaviors, parenting,
Civil Rights, are based on studies of publicly funded pre-K programs across the US
feeding/nutrition, community resources, support to child care/
and relied on acknowledged or reported expulsions. Therefore, though the data
preschools and more. 877-705-KIDS (5437),
indicates that suspensions and expulsions affect thousands of young children each
birthtofivehelpline.org
year, they are an underestimate of the problem. They do not include rates at private preschool programs, and they do not include what are known as “soft
Early Care and Education Inclusion Program: Designed to
expulsions”—the many ways in which families find themselves on the other side of
help preschool and child care providers support children ages
the preschool door without having been explicitly told that they may no longer bring
birth to 5 with developmental delays or disabilities in the
their child. For example, when a parent is persistently asked to pick up his or her
classroom. With coaching and training, preschools and child
child in the middle of the work day because of difficult behavior, at some point that
care providers find they are better equipped to serve all
becomes an untenable child care arrangement.
children, not simply those who are typically developing or just those with special needs. 602-633-8454, swhd.org/inclusion
To be clear, not all settings are optimal for all children. When a child care provider or teacher and a family agree on this point and another placement is sought, that is
Professional Development and Training: Nationally-
not an expulsion. Expulsions are unilateral decisions on the part of the provider or,
recognized education and training programs to professionals
as in soft expulsions, decisions made by families because they feel they have no
and organizations working with young children across Arizona,
choice. Such exclusionary practices are harmful to children and families and can
the U.S. and internationally. 602-266-5976, swhd.org/training
influence a number of negative developmental, health and educational outcomes. Quality First: Arizona’s Quality Improvement Rating System
Young students who are suspended or expelled are as much as 10 times more likely
partners with early childhood providers to provide coaching and
to drop out of high school, experience academic failure and grade retention, hold
assessment to improve early care and education environments
negative views of school, and face incarceration than those who are not. Although
so young children can begin school safe, healthy and ready to
the majority of the research on the adverse effects of school suspensions and
succeed. 877-803-7234, qualityfirstaz.com
expulsions has focused on elementary, middle and high school settings, there is evidence that earlier suspensions and expulsions are associated with such
Smart Support: Arizona’s Mental Health Consultation System
experiences in later school grades. Therefore, we have good reason to worry that
that partners early childhood mental health consultants with
the negative outcomes of these disciplinary practices that we know affect older
child care providers to promote the social and emotional
children also portend poorly for little children.
development of all children in care and help providers respond to children with behavioral challenges. 866-330-5520,
There is a preschool “chain of expulsion” that is often set in place, one leading to
swhd.org/smartsupport
another, and is a pattern well-known to those working in early care and education settings. A child (and family) is thus experiencing repeated failure without the underlying emotional, psychological, developmental or other problems being addressed. All of the promise that early care and education can hold is lost to these children, including the consistent opportunity to learn early academic concepts. Experience establishes expectations. If we want children to expect to succeed in the next place that is ca lled “school” with the next person who is called a “teacher,” if we want them to feel that school is a place for them, their early experiences have to teach them that.
The promise that good early care and education holds is substantial. Preschoolers are too young yet to know this lesson, but we adults must never forget it: You should always keep your promise.
The Role of Healthcare Professionals in Stopping Bullying R. BRADLEY SNYDER | THE DION INITIATIVE AT ARIZONA STATE UNIVERSITY
B
ullying is a real problem. Nationwide, research from
healthcare professional responds effectively. Not doing so is
the Centers for Disease Control and Prevention
tantamount to re-victimizing the child.
indicates that 20 percent of high school students are bullied each year, and the rates are higher for
For those healthcare professionals fortunate enough to work in an
students in elementary and middle school. Locally, data from the
integrated care environment, an
Arizona Youth Survey shows that 42 percent of eighth graders, 31
effective response is as simple
percent of tenth graders, and 23 percent of twelfth graders are
as an immediate referral. The
bullied each year.
mental health professionals on the team will be connected with
Bullying can be traumatic to victims, contributing to mental health
the local schools and will know
problems (e.g., depression, etc.) and physical health problems (e.g.,
whom to contact to ensure that
cancer, strokes, etc.) over a lifetime. Consequently, it is incumbent
appropriate steps are taken to
on healthcare professionals to intervene when they know or suspect
treat the bully and victim while
that a child in their care is being bullied.
eliminating opportunities for the bullying to continue.
Unfortunately, many of the signs and symptoms associated with
Outside of integrated care, the
bullying have other causes. For example, children who are being
healthcare professional may
bullied often complain of somatic illnesses (e.g., headaches,
need to leverage her or his
stomachaches, etc.), have unexplained injuries and bruises, and
professional network in order
R. Bradley Snyder,
show waning interest in hobbies and other activities they once found
to secure mental health
Executive Director, Dion Initiative
enjoyable. In other words, a bullying victim may present as
assistance. Regardless, I
for Child Well-Being and Bullying
depressed, neglected, or even abused.
recommend that healthcare
Prevention
professionals be present during the referral process. I believe that Unique to bullying (compared to other maladies) is school. Virtually
confidence is preserved better when the victim witnesses firsthand the
every instance of in-person bullying occurs on or near school
handoff from the trusted adult to another professional.
grounds. As a result, victims of bullying typically exhibit a sudden decrease in academic achievement or a general aversion to school
Finally, it is important to recognize that bullies
(hence the somatic illnesses and other attempts to avoid
work hard to make victims believe they deserve to be
attendance).
bullied. They do not. It is critical that healthcare professionals never ask victims why they are being
In addition to recognizing the signs and symptoms of bullying, it also
bullied. Victims know the reasons the bullies give,
is important for healthcare professionals to know how to intervene
but it hurts them to repeat those accusations to the
when they know or suspect bullying. Every evidence-based bullying
trusted adults in their lives.
prevention program and national media campaign instructs children to tell trusted adults when they see or experience bullying (indeed
The Dion Initiative for Child Well-Being and Bullying Prevention is a
scientific studies of bullying indicate that bullying will not resolve
resource and research program that promotes environments that
without adult intervention). If the trusted adult in the life of a bullying
foster the health, well-being, and academic success of children. Learn
victim is a healthcare professional, then it is critical that the
more at http://www.dioninitiative.org.
Pediatric Digest, Summer 2018 Page 10
PROTECTING YOUTH FROM BULLING A PROVIDER’S PROSPECTIVE: CLINICIANS AND CAREGIVERS CAN BE ON THE LOOK OUT FOR SIGNS OF BULLYING
FUNDA BACHINI, MD| PHOENIX, AZ I often see kids in my clinical work who
want to tell because they are scared of
schools may blame the child who is a
present with school refusal. Many
retaliation, so make sure they know
victim of bullying as they may have
times this is due to social difficulties at
that they are safe. Next, validate that
started bullying other kids in response,
school. Research shows that 28% of
the child is having difficulty but don’t
or they may not want to provide the
children grades 6- 12 have experienced
overstate the problem. Encourage them
necessary services. If a parent is
bullying. Most commonly, bullying is
to tell a grown-up when this occurs at
having difficulty getting a response
verbal, but can be physical or online as
school. Keep the lines of
from the school suggest escalating it to
well. Although there are laws at
communication open. Parents and kids
the district level.
federal, state, and local levels to
can come up with a detailed plan of
address bullying and most schools have
who the child can speak to and a
Navigating the school can be
a zero tolerance policy; parents are
specific location to go to if they
a tricky process. Providers
often at a loss as to what they can do
encounter a problem.
should validate concerns of the child and family and
to help. Unfortunately, bullying is often not reported, but clinicians and
Although providers can be a useful
empower them to reach out to
caregivers can be on the lookout for
resource for parents, schools most
the schools. Providing them
signs. For example, if the child
often want to hear from the parents
becomes more withdrawn, begins to
themselves. In speaking with the
refuse school, or begins to act out in
school, parents are the most effective
uncharacteristic way. They may show a
and important advocate for their child.
change in their sleep or eating habits.
Encourage parents to write a letter,
It is also common for kids to present
very specifically outlining incidents that
their psychological stress through
occurred and providing as much
somatic symptoms. For example, onset
information as possible. I have found it
of frequent GI upset or headache,
helpful for parents to also offer some
especially when it’s time to go to school
solutions. For example, changing class
may be signs of a larger issue. If any of
or lunch schedules to avoid interactions
these risk factors are identified, it is
with the children in question or having
important to speak to both the child
the child walk in the halls with a buddy.
and the school.
Many schools offer programs to help
with resources such as Raising Special Kids, stopbullying.gov, and Notmykid.org can be helpful. If the child has AHCCCS, they may be able to get an advocate to help them. If the child continues to have difficulties refer them to a counselor or psychiatrist.
Funda Bachini, MD specializes in Psychiatry at Phoenix Children's Medical Group.
children who are the targets of bullying In speaking with the child, first, provide
or to encourage bystanders to speak
reassurance. Sometimes they don't
up. It can be frustrating at times as
Pediatric Digest, Summer 2018 Page 11
The Pediatrician’s Role in Promoting School Safety VEENOD L. CHULANI, MD, MSEd, FSAHM, CEDS | PHOENIX, AZ Millions of children spend roughly 7 hours per day,
national tragedies, however, will be forever changed by trauma, loss,
180 days each year in school.
and the breach in their sense, safety and security. Firearm-related deaths are the third leading cause of death overall among US children
The American Academy of Pediatrics (AAP) acknowledges the
aged 1 to 17 years and the second leading cause of injury-related
interdependence of health and education and recognizes the
death, surpassed only by motor vehicle injury deaths. Everyday we
important role pediatricians’ can play in promoting the health and
experience a Parkland, a Columbine, and Sandy Hook, as almost 20
well-being of children and youth in educational settings. The
children and youth lose their lives daily to firearm-related homicide,
Academy encourages pediatricians to understand their roles and
suicide, and unintentional injuries. Additionally, the firearm-related
potential contributions to schools as integral members of the school
violence that we see enacted in our schools is a spillover from what
health team. Competencies that relate to the role of pediatricians in
lies outside its perimeters and reflect our broader society. Ours is a
educational settings have long included screening children for school
society where multiple factors, including weak firearm safety
readiness, knowing infection control policies in schools, and serving
legislation, fragmented mental health and substance abuse services,
as a consultant to physical education, sports, and wellness programs,
and an active lobby that loudly invokes the right to bear arms while
among others.
wielding huge influence.
This Pediatric Digest issue dedicated to exploring the role of
Ultimately, we must develop, implement, and evaluate comprehensive
pediatricians in schools comes on the heels of yet another mass
solutions that not only create safe schools but also prevent firearm
school shooting in Parkland, Florida, killing 17 children and adults and
related death and disability. We will need to invest in effective security
injuring 15 more. As advocates for safe and secure environments
technology and maintain high levels of preparedness in our emergency
where our young can learn and thrive, pediatricians must reaffirm our
response plans. We will need to close dangerous loopholes in our
commitment to children and youth and respond to the reoccurring
systems for reporting mental illnesses and conducting background
national tragedy of mass school shootings. How can pediatricians
checks to keep firearms away from those who may pose threats to
meaningfully lead the charge in securing safe and positive school
themselves or others. As pediatricians, we must broaden the scope of
environments for our children and youth?
what it means to promote school health and safety to encompass how we can best be resources to our patients, families, schools, and
The seemingly frequent mass school shootings that capture national
communities in the areas of prevention and response to firearm
attention account for only a small percentage of all firearm-related
violence. This may include informing schools on trauma-informed
deaths that occur in this country. The students, friends, parents,
approaches and addressing obstacles to communication and exchange
loved ones, and communities most touched by our reoccurring
of information between schools and pediatricians because of Health Insurance Portability and Accountability Act (HIPAA) and the Family Educational Rights and Privacy Act (FERPA) to better prevent, identify, and treat serious emotional health concerns early. As we explore all avenues for prevention, examining the meaning of the right to bear arms should by no means be sacrosanct. Of what good is a right if children and youth are hurt in its broad exercise? Additionally, individual rights have limits - they end where the rights of others begin. Children and youth have a right to safe and secure environments where they
Pediatric Digest, Summer 2018 Page 12
can learn and thrive, and we have an enduring
to violence, are also critically important. Additionally,
obligation and social contract with them to ensure
pediatricians are encouraged to integrate screening for
this.
firearm access during routine health visits, asking both adolescents and parents for firearm availability.
Even as we work towards effective multi-sectoral
Delivering a firearm safety message regardless of
solutions to promote systems-level change, it is
reported firearm access and counseling parents on
important that we recognize the critical role every
safe storage or eliminating teenager’s access to
pediatrician can play in promoting school safety
firearms in higher risk situations involving depressed,
and preventing firearm-related death and disability.
suicidal, and emotionally disturbed youth are also key.
Pediatricians are encouraged to advocate for smart firearm safety legislation, especially in the face of
May this latest mass school shooting compel us to
compelling evidence of its efficacy as a public
find, despite our political and ideological differences,
health intervention. The American Academy of
common ground in our commitment to provide for the
Pediatrics advocates for stronger state and federal
Veenod L. Chulani, MD, MSEd,
gun laws that protect children and youth, including a ban on assault weapons like the one used in the Florida school shooting. The Academy
FSAHM, CEDS, AzAAP Medical
safety, security, and well-being of our children and youth.
Director, Quality of Care and Child Safety, Section Chief, Adolescent
also calls for stronger background checks,
Medicine, Phoenix Children’s
solutions addressing firearm trafficking, and encouraging safe firearm storage. Legislation that
Hospital
References: 1.Council on School Health. American Academy of Pediatrics. The Role of the School Physician. Pediatrics 2013;131:178–182.
2.Beth Rezet, Wanessa Risko, Gregory S. Blaschke. Competency in Community
ensures that children and their families have access to appropriate
Pediatrics: Consensus Statement of the Dyson Initiative Curriculum Committee
mental health services, particularly to address the effects of exposure
2005; 115 (Supplement 3) 1172-1183).
PEDIATRICS IN THE RED ROCKS SUMMER CONFERENCE June 29-July 1, 2018 Plan on attending the 41st Annual Course of Pediatrics in the Red Rocks taking place at the beautiful Hilton Resort and Spa!
New This Year! We are very excited to offer attendees an expanded agenda with an increased amount of CME credit claiming opportunity, and for the first time ever, attendees have the opportunity to earn 10 Maintenance of Certification (MOC) Part 2 points. These improvements were created with the benefit of our members in mind, adding value to the overall conference experience.
Early bird registration discounts and special rates for members are being offered! www.AzAAP.org/Pediatrics_in_the_Red_Rocks
The ABCs of Concussion Management KRISTINA M. WILSON, MD, MPH, CAQSM, FAAP | PHOENIX, AZ As a product of several generations of teachers, I have jokingly referred to myself as the “black sheep” of my family to my patients and their families. When I first entered into medicine, I never expected that my career would take me full circle back into working with the school system. As the Medical Director of the Brain Injury and Concussion Program at Phoenix Children's Hospital, I interact directly and indirectly with school nurses, counselors, principals, deans, athletic trainers, and athletic directors on a daily basis. It is my goal in Kristina M. Wilson, MD, MPH, CAQSM, FAAP, AzAAP Board Member, Medical Director, Pediatric and Adolescent Sports Medicine, Phoenix Children’s Hospital
the next few moments to share my experiences to provide a framework for providing the best care to the patient with a mild traumatic brain injury as they transition back into the school environment.
One of the biggest obstacles we face particularly in the primary schools is helping school administrators and teachers understand the link between school and traumatic brain injury (TBI). Currently, there is not a standard way of returning students to the classroom. Guidelines are based off of best practice from expert
opinion. This leaves the door open for resistance to recommendations and often puts the patient and their family in a difficult position between the provider and school teachers and administers that leads to an unsupportive school environment, ultimately prolonging recovery. Furthermore, there are no physical manifestations for most mild traumatic brain injuries leading to poor buy-in from teachers, administrators, peers, and coaches. Education and regular communication are our most effective tools to tackle these barriers.
The education starts in the office with the patient and their family. The school environment in addition to the expectations of learning and memory are the most cognitively demanding activities asked of the brain of a child. At the same time, school is the single most important activity to maintain attendance at or return to after head injury. The key to management is helping patients and their families bridge the link between symptoms and triggers. This allows for the balance between not over restricting, but restricting enough to allow the brain to heal while returning to normal activity.
Recently, one of my patients described her experience of an assembly she attended while she was still recovering. “My teacher was leading the assembly for the geography bee. She brought us to the cafeteria and sat us in rows of chairs behind the podium. Two of my friends sat on either side of me so that I would be able to hear them talk with me throughout the assembly. Immediately I could hear the clanging of the trays off in the distance. The noise began to intensify as my friends started talking to me as others around us were all having different conversations. Then they started using the microphone with the sound system in the cafeteria for the assembly. I couldn’t focus on any one sound and they all began to intensify in my head which intensified the pain in my head. Then the lights in the room became too intense for me to have my eyes open and I laid my head down in my lap and couldn’t remember why we were in the cafeteria.” This story highlights how
Pediatric Digest, Summer 2018 Page 14
challenging the school environment itself is post head injury. The hallmark of concussion management is finding a balance between cognitive exertion and rest.
Our job as medical providers taking care of these children is helping them to identify the triggers in the school environment and request that modifications be made to enable the students to return to learn successfully while at the same time allowing their brain to fully recover. This is where communication with the school starts. Ideally, return to learn should be facilitated and supported in a team based approach. The AAP recommends at least one member per team and identifies 4 teams (Halstead et al. 2013). These include the family, medical, school academic, and school physical activity teams. The membership and roles and responsibilities of these teams are listed in table 1. This approach brings all stakeholders into the management of the student allowing for a collaborative approach that supports the student in his/her return to an academic setting.
It is important for providers to know the terminology for the support he/she is asking for the student. Unless we are able to speak the language with the school and share this knowledge with the parents and guardians of the students we are not able to effectively empower families to be advocates for their brain injured child. In the public school setting, there are three levels of academic support, academic adjustments, accommodations, and modifications. Academic adjustments are generally what are needed for the typically recovering concussion that is expected t o resolve in 3-6 weeks. These adjustments are temporary and do not involve changing the curriculum. They often include requests such as decreasing the workload, providing increased time for all work including quizzes and tests, shortened days or class periods, permitting short breaks throughout the day, wearing sunglasses, etc. Academic accommodations are for students with more significant injuries for which recovery is expected to take 3 months or more. This request involves creating a document called a 504 plan which mandates their teachers to provide the agreed upon accommodations for the student in school. The student’s legal guardian must make the request for a 504 plan after which a meeting of the concussion team including the teachers, councilor, athletic trainer (when applicable), dean of students, the student and guardian. The medical provider should also be involved in this meeting at least through written documentation of recommended accommodations for the student based on needs assessed by you and the rest of the concussion rehabilitation and neuropsychology teams. Academic modifications are the highest level of support provided to a student and
Pediatric Digest, Summer 2018 Page 15
involve changing the curriculum for the student. An IEP is permanent and follows the student throughout their
Symptom
Impact on school
Strategies to control symptoms
Headache
Most common symptom Hinders ability to focus/concentrate Variable throughout the day Often have triggers Fluorescent lights Loud noises Sustained focus/concentration
Frequent breaks Identify aggravators – reduce exposure Rest periods – quiet environment
May be indicative of injury to the vestibular system Difficulty with standing quickly or walking in crowded environment Provoked by visual stimulus Rapid movements Videos
Put head down Early dismissal from class to get to next class and avoid the crowded hallway
Visual symptoms Light sensitivity Double vision Blurry vision
Struggle with the school environment Slide presentations Movies Smart boards Computers Tablets Artificial lighting Difficulty reading and copying Difficulty paying attention to visual tasks
Reduce exposure to screens Reduce brightness to screens Permit hat/sunglasses Audiotapes/books Turn off fluorescent lights Seat in center of classroom (blurry vision)
Noise sensitivity
Struggle with various aspects of the building Lunchroom Vocational classes Music classes Physical education class Hallways Organized sport practices
Lunch in quiet area with 1-2 classmates Avoid classes with excessive noise Avoid gym Ear plugs Early dismissal to change classes Notify parents for fire drills – keep athlete at home
Difficulty with concentration or remembering
Challenges learning new tasks and comprehending new materials Difficulty recalling and applying previously learned material Lack of focus in the classroom Trouble with test taking Trouble with standardized testing Reduced ability to take drivers education safely
Avoid testing No completion of major projects Extra time for non-standardized tests Post-pone standardized testing One test per day Preprinted notes/note taker/ scribe Reader for oral tests
Sleep disturbances Excessive fatigue Insufficient sleep Difficulty getting to sleep/frequent waking Excessive napping due to fatigue
Interferes with memory for new or past learning or ability to attend and focus Tardiness Excessive absences Sleeping in class Further disruptions in the sleep cycle
Late start Shortened school day Rest breaks
academic journey including to a state university if needed.
This is reviewed and revised annually. Table 2 lists common symptoms, their impact on school and learning, and strategies to control symptoms which then need to be
Dizziness/lightheadedness
communicated clearly to the school. Concussion for all children is unique and the recommendations should be
tailored to each specific child based on their needs.
In conclusion, it is important for us to SEEK a smooth return to the learning environment where the student and their family feel supported to ensure a successful outcome.
1 2 3
Speak the language – know how to ask for the support your patient needs
Educate all stakeholders – patient, family, and school personnel
Empower parents to be advocates for their child – close follow-up with the school, request academic
support when needed, i.e. 504 plan
4
Know your team (family, medical, school academic, and school physical activity) and communicate in
writing with all correspondence between team members
Return to Learn Teams
Members of team
Roles and responsibilities
Family team
Student Parents Guardians Grandparents Peers Teammates Family friends
Enforce rest Reduce stimulation Parent makes ultimate decision on return to learn
Medical team
Emergency department staff Primary care provider Concussion specialist Primary care sports Neurology Neurosurgery Clinical psychologist Team and/or school physician
Evaluate Assess Lesional injury Neurologic injury Treatment Cognitive rest Physical rest
School academic team
Teacher School counselor School psychologist Social worker School nurse School administrator School physician
Coordinate return to cognitive exertions Facilitate appropriate level of academic adjustments Understand effects of concussion on learning
School physical activity team
School nurse Athletic trainer Coach Physical education teacher Playground supervisor School physician
Safeguards the student from further injury Immediate removal for suspected injury Follow stepwise return to activity progression
Reference: Halstead ME, et al. Council on Sports Medicine and Fitness; Council on School Health: Returning to
learning following a concussion. Pediatrics 2013;132(5):949-957.
From ADHS: The Role of Healthcare Professionals Working with Schools
4 5
KATHY LEVANDOWSKY | OFFICE CHIEF |
within the school.
OFFICE OF CHILDREN WITH SPECIAL HEALTH CARE NEEDS (OCSHCN)
Understand family cultures and the impact it may have on caring for a child with special health care needs.
Establish a working relationship with the school nurses who care for children with chronic conditions (special health care
needs) to ensure that the child’s health plan is executed effectively
6
Communications with school nurses concerning your patients should be clear and detailed to help guide school nurses in
overseeing the care of individual children with chronic conditions In May of 2016, the American Academy of Pediatrics issued a policy statement, calling for a minimum of one full-time registered nurse in every school. Across Arizona school nurse staffing patterns varies widely between schools having health aides to registered nurses. Registered Nurses are not in every school. Now more than ever the relationship between the healthcare professional and the school nurse is increasingly important for the health and wellness of children with chronic conditions (special health care needs).
(special health care needs).
7
medical management in areas such as attention-deficit/hyperactivity disorder, diabetes, life-threatening allergies, asthma, seizures and other medically complex needs. Often a school nurse is a liaison between school personnel, family, health care professionals, and the community.
contact between the school nurse and you for questions
regarding:
School nurses today
monitor more children with special health care needs, and help with
Designate someone in your office to be the central point of
Medication management. School-based screenings for vision and hearing which may require further evaluation and treatment.
Health care plans, diabetic care plan, asthma care plan, emergency care plan, etc.
8
Offer direct support of school nurses by serving as an expert for children with chronic illnesses on school wellness policy
committees, school health advisory committees, emergency preparedness committees, or other school-related decision-making
Pediatricians who work closely with school nurses will serve all of their patients better. Collaboration among pediatricians, families and the school nurse or school medical team is increasingly critical for optimal health care in both office and community settings. Here are some tips for pediatricians and other healthcare professionals working with the schools in their community.
bodies.
9
School-based screening for vision, hearing, or other conditions may require coordination between local physicians and the
school nurse to ensure students are referred for additional evaluation and treatment, and for communication with students, families, school administration, and the community.
TIPS:
1
Kathy Levandowsky is Office Chief for the Office of Children with Ask your young patients school-related questions, such as
Special Health Care Needs, Bureau of Women’s and Children’s
whether health problems contribute to their chronic
Health, Arizona Department of Health Services.
absenteeism.
2
Include school contact information within the student’s electronic health record (EHR) and share relevant information
with the school nurse.
3
References: 1.Office for Children with Special Health Care Needs, http://www.azdhs.gov/ prevention/womens-childrens-health/ocshcn/index.php 2.National Standards for Systems of Care for Children with Special Health Care Needs, http://cyshcnstandards.amchp.org/app-national-standards/#/
Develop relationships with the student and family to understand what a typical day for the child and the family looks
like in managing the child’s health care needs.
3.Got Transition, http://www.gottransition.org/about/index.cfm 4.The Pediatrician’s Role in Optimizing School Readiness by the Council on Early Childhood, Council on School Health. http://pediatrics.aappublications.org/ content/pediatrics/early/2016/08/25/peds.2016-2293.full.pdf Pediatric Digest, Summer 2018 Page 17
STOCK INHALERS FOR SCHOOLS:
New Legislation in the State of Arizona LYNN B. GERALD, PhD, MSPH, et al.| TUCSON, AZ Asthma affects approximately
leading to increased school absenteeism,
school administrators, school nurses, the
10% of children in the United
increased levels of stress and substantial
School Nurse Association of Arizona
States. More than half of these children
health care expenditure from EMS and
(SNOA), State Board of Education, the
will experience a sudden asthma attack
ED utilization.7-9
American Lung Association, the Arizona
1
Asthma Coalition, and the University of
leading to 750,000 emergency department visits and 200,000 hospitalizations each
Asthma attacks resulting in EMS and ED
Arizona Asthma and Airway Disease
year.2 In 2015, 219 children died as a
utilization are largely avoidable with a
Research Center led to Arizona becoming
result of an asthma attack. Short-acting
simple, low-cost solution: stock rescue
the 9th state to adopt legislation
bronchodilators (e.g., albuterol = a rescue
inhalers. Schools can purchase a single
permitting the use of stock inhalers in
medication) are easy to administer, safe,
inhaler containing a short-acting
schools. H.B. 2208 provides specific
and quickly relieve symptoms of an asthma
bronchodilator that can be used by
guidelines that increases the availability of
attack if used appropriately. Because an
anyone who experiences sudden
rescue medication in schools while
attack can occur without any warning, all
respiratory distress. Implementation of a
protecting schools, their employees, and
children should have access to this
stock inhaler program in a large public-
prescribers from civil liability and includes
medication while at school.4
school district in Arizona managed 222
several provisions:
asthma attacks in 55 children and 22
1
3
Unfortunately, 80% of children with
schools. An evaluation of the program
asthma do not have access to rescue
demonstrated a 20% reduction in
medication at school. This problem affects
respiratory-related 9-
an emergency protocol to
children across the socioeconomic
1-1 calls and 40%
guide medication
reduction in EMS
administration.
transports. School
2
spectrum: rich and poor, urban and rural, private-schooled and public-schooled.
5,6
Public and charter schools that elect to administer inhalers shall develop
While some children simply cannot afford
nurses reported
this medication, children may also forget to
lower job-related
bring their medication with them, the
stress but described
employees per school must
medication may have expired, or there are
concerns with liability
complete an online training
no remaining doses. These situations leave
regarding medication
curriculum on an annual
schools with limited options during a
administration.6
basis.
bring the child’s rescue medication; (2) call
Collaboration
9-1-1 and have on-site treatment; or (3)
between pediatric
3
have emergency medical services (EMS)
pulmonologists,
inhaler program are
transport the child to the nearest
pediatricians,
required to have a
emergency department (ED). Such events
pharmacists, county
standing order and
remove children from the classroom
health departments,
prescription issued by a
respiratory emergency: (1) call a parent to
A minimum of 2 designated
Schools that implement a stock
Pediatric Digest, Summer 2018 Page 19
4.National Asthma Education and Prevention
chief medical officer of a county health
University of Arizona; Conrad Clemens,
department, physician, or nurse
MS, MPH, Professor of Pediatrics and
practitioner.
Public Health, Associate Dean for Graduate
4
Medical Education, University of Arizona;
November 5, 2017.
Persons who issue the standing
Lynn B. Gerald, PhD, MSPH, Professor/
5.Gerald JK, Stroupe N, McClure LA, Wheeler L,
medical order or trained employees
Canyon Ranch Endowed Chair, Mel and
Gerald LB. Availability of asthma quick relief
of schools are immune from civil liability.
Enid Zuckerman College of Public Health,
5
Associate Director for Clinical Research,
Program. How Asthma-Friendly Is Your School. 2008; www.nhlbi.nih.gov/files/docs/public/lung/ asthma_friendly_checklist_en.pdf. Accessed
medication in five Alabama school systems. Pediatric allergy, immunology, and pulmonology. 2012;25(1):11-16.
No school will be required to
Asthma and Airways Disease Research
6.Gerald LB, Snyder A, Disney J, et al.
implement a stock inhaler program if
Center, University of Arizona.
Implementation and Evaluation of a Stock Albuterol Program for Students with Asthma. Annals of the
no funding is available; however, schools
American Thoracic Society. 2016;13(2):295-296.
may accept donations or grant monies for the purchase of inhalers and valved-holding chambers.
References: 1.Moorman JE, Akinbami LJ, Bailey C, et al. National surveillance of asthma: United States, 2001-2010. Vital & health statistics Series 3,
This article was written in collaboration by
Analytical and epidemiological studies. 2012(35):1
the following authors: Ashley Lowe, BS,
-58.
Mel and Enid Zuckersom College of Public
2.Akinbami LJ, Moorman JE, Liu X. Asthma
Health, Research Specialist, Asthma and Airway Disease Research Center, University
prevalence, health care use, and mortality: United States, 2005-2009. National health statistics reports. 2011(32):1-14.
of Arizona, Melissa More, MD, Assistant
3.Centers for Disease Control and Prevention. Most
Professor of Pediatrics, Co-Director of Global
Recent Asthma Data. Mortality 2017;
Health in the College of Medicine, Tucson
www.cdc.gov/asthma/most_recent_data.htm.
Unified School District Physician Consultant,
Accessed November 4, 2017.
7.Moonie SA, Sterling DA, Figgs L, Castro M. Asthma Status and Severity Affects Missed School Days. Journal of School Health. 2006;76(1):18-24. 8.Moonie S, Sterling DA, Figgs LW, Castro M. The relationship between school absence, academic performance, and asthma status. Journal of School Health. 2008;78(3):140-148. 9.Akinbami OJ, Moorman JE, Bailey C, et al. Trends in asthma prevalence, health care use, and mortality in the United States, 2001-2010. 2012.
Preparing for the Future: Vaccinate Before You Graduate BY DEBBIE MCCUNE DAVIS | PHOENIX, AZ The Vaccinate Before You Graduate and Off to College campaigns were initiated by The Arizona Partnership for Immunization (TAPI) to educate young adults on the importance of receiving required and recommended vaccinations. As students prepare for college/trade school and life, age appropriate vaccines such as Tdap, Meningitis ACWY, Meningitis B, HPV and Flu are recommended to establish or maintain protection from disease. For those living in crowded settings like dormitories and interacting socially in environments where they are at higher risk these vaccines can make a difference between life and death if outbreaks occur.
The first step of these projects began when TAPI invited the medical directors of the three state universities: Northern Arizona University (NAU), University of Arizona (U of A) and Arizona State University (ASU) into a conversation. A graduate student’s research had identified the need to develop a unified approach to immunizations required and recommended for admission to our state universities. Under the guidance of Dr. Karen Lewis and Dr. Andrea Houfek
Use these tips to make sure your patients are up-to-date:
1
Promote staff education
2
Encourage employees
vaccine recommendations
Immunizations (TAPI)
Use every patient encounter as an opportunity to immunize
Develop and implement Immunization tracking procedures to assist with patient follow-up.
Review patient immunization record at every visit Consider electronic health record prompts or flag patient chart when vaccinations are due
Keep screening Checklist on hand and provide fact sheet and handout to all patients
families about vaccines needed for college entry in Arizona. See
examples here: http://www.whyimmunize.org/product/vaccinate-
5
The Vaccinate Before You Graduate message is relevant to teens 15-
to be completely
3 4
Arizona. Once accomplished, TAPI launched “Off to College” to educate
before-you-graduate/
Debbie McCune Davis, Executive Director, The Arizona Partnership for
immunized
following ACIP guidelines, common language was written to provide guidance to recommended vaccines for college bound students in
on all updated ACIP
Implement standing orders for nurse only visits
Send patient reminders by postcards, phone calls or text as the most effective means of improving adolescent vaccination rates
17 and promotes the idea that updated vaccinations are a major part
Working together, AZ universities, high schools and
of the college readiness process much like filling out a FAFSA and
physicians are ensuring bright futures for AZ teens.
taking the SAT/ACT. New emphasis on a 16-year-old well visit is the perfect opportunity to review a teen’s immunization status and the physician’s role is very critical. Consistent with the Bright Future’s guidance, the adolescent visit provides an opportunity to review the
Get teens in for their 16 year well visit, get them ready and vaccinate them for a healthy future! Links to Resources:
current immunization status and make a strong recommendation for
https://www.whyimmunize.org/free-materials/
completion of any recommended or required vaccines. The well visit
http://www.adolescenthealth.org
encourages adherence to preventive guidance and screenings during
https://brightfutures.aap.org/Pages/default.aspx
adolescence and may prompt a conversation with the teen about their future plans and the importance of preventative health.
https://meningitisbactionproject.org http://www.nmaus.org/educational-resources/preteen-teen-vaccines/ https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/ adolescent-sexual-health/Pages/HPV.aspx
Vaccine recommendation from a health professional is an influential
https://www.give2mcv4.org/content/uploads/2017/03/rationale-for-16-
motivator to get immunized and emboldens adolescents to participate
year-old-immunization-platform.pdf
in their healthcare choices. Ideally, with your help all students will
http://www.immunize.org/catg.d/p4022.pdf
arrive at Arizona universities with an up-to-date immunization record!
https://www.aap.org/en-us/Documents/immunizationschedule2017.pdf
Pediatric Digest, Summer 2018 Page 21
What Does “Eligible” for Special Education Mean? An Explanation From the School Setting JONATHAN MOORE AND NICOL RUSSELL | ARIZONA DEPARTMENT OF EDUCATION Background:
Arizona is a vast state and much of it includes rural and isolated rural areas. While Coconino County is the largest county in the
state in area, it has a small population—seven people per square mile. Rural students are often bused to school and that travel may require more than an hour spent each way; in addition, many of the dirt roads become impassible during the winter season. Arizona has 22 sovereign Native American tribes, one of the highest populations of Native Americans in the United States. In contrast to the isolated rural local education agencies (LEAs), Arizona also has large urban and suburban LEAs. This number does not account for those in private schools, those no longer in school, and those in early childhood education. To receive special education in schools, a child who is impacted by social, communication, and behavioral challenges as defined in the Individual with Disabilities Education Act (IDEA) is evaluated by a team of professionals who know the child. This team, which includes the parents, then determines if the child requires specialized instruction to benefit from the school experience. Eligibility criteria is defined by the State of Arizona and may be found in the Arizona Revised Statutes, Chapter 15. Once a child is found eligible to receive special education services, the team develops an Individualized Education Program (IEP) for the student.
Screening and Evaluation to Determine Eligibility: Screening— A screening procedure is a short, economical, easily-administered measure designed to determine whether a more comprehensive evaluation is needed. A screening instrument cannot be used as part of an evaluation/Comprehensive Developmental Assessment (CDA). A screening can be accomplished using a tool that has already been standardized. A district may choose to design their own screening procedures to screen in all five developmental areas. To ensure a fair and reliable process it is important that districts use a consistent screening process for all children. Districts are encouraged to accept screening information from other
Pediatric Digest, Summer 2018 Page 22
agencies (e.g. Head Start, Family and Child Education (FACE), et. al), rather than conducting another screening. Districts should track referrals from other agencies. If data reveals an inordinate amount of referred children who do not qualify for services, then district staff should work with the referring agency to ensure more reliable referrals through shared professional development and decision making. Select examples of developmentally appropriate screening tools are:
Ages and Stages Questionnaires (ASQ) This is a general developmental screening tool. Parent-completed questionnaire; series of 19 age-specific questionnaires screening communication, gross motor, fine motor, problem-solving, and personal adaptive skills; results in a pass/fail score for domains.
Communication and Symbolic Behavior Scales (CSBS) Standardized tool for screening of communication and
Associate Superintendent, K-
symbolic abilities up to the 24-month level; the Infant Toddler Checklist is a 1-page, parent-completed
12 Academic Standards,
screening tool.
Jonathan Moore, Deputy
Parents’ Evaluation of Developmental Status (PEDS) This is a general developmental screening tool. Parentinterview form; screens for developmental and behavioral problems needing further evaluation; single
Arizona Department of Education
response form used for all ages; may be useful as a surveillance tool.
Modified Checklist for Autism in Toddlers (MCHAT) Parent-completed questionnaire designed to identify children at risk for autism in the general population.
Screening Tool for Autism in Toddlers and Young Children (STAT)
Evaluation— A Comprehensive Developmental Assessment (CDA) (sometimes referred to as a multidisciplinary team evaluation) is required for children ages 3-5. It is a full and individual evaluation of the child in all developmental areas: cognitive, motor, communication, social/emotional, adaptive development, sensory and vision and hearing should also be included. A thorough review of existing data is the beginning of any evaluation process, and allows a team to determine the need for further data collection or to determine eligibility based on current data. When further data collection is required to determine eligibility, consent for evaluation is obtained, a CDA is completed using existing data, criterion referenced assessments, norm-referenced assessments, observation and parent input. However, for the purpose of determining eligibility in preschool, at least one normreferenced assessment instrument to obtain standard deviation information must be used to determine if eligibility
Nicol Russell, Deputy Associate Superintendent, Early Childhood Education, Arizona Department of Education
criteria is met. The evaluation team shall determine eligibility based on the preponderance of the information presented. The final responsibility for the evaluation process and eligibility lies with the Public Education Agency (PEA). Select examples of diagnostic tools:
*Autism Diagnosis Interview – Revised (ADI-R) A clinical diagnostic instrument done by pediatric assessment teams accepted by schools for assessing autism in children and adults. The instrument focuses on behavior in three main areas: reciprocal social interaction; communication and language; and restricted and repetitive, stereotyped interests and behaviors. The ADI-R is appropriate for children and adults with mental ages about 18 months and above. *This is a lengthy tool often used for research. It is not a tool generally used in the pediatric office.
Autism Diagnostic Observation Schedule – 2 (ADOS-2) A semi-structured, standardized assessment of social interaction, communication, play, and imaginative use of materials for individuals suspected of having Autism Spectrum Disorder (ASD). The observational schedu le is designed to be administered to individuals according to their level of expressive language.
Childhood Autism Rating Scale (CARS) Brief assessment suitable for use with any child over 2 years of age. CARS includes items drawn from five prominent systems for diagnosing autism; each item covers a particular characteristic, ability, or behavior.
Gilliam Autism Rating Scale – Second Edition (GARS-2) Assists teachers, parents, and clinicians in identifying and diagnosing autism in individuals ages 3 through 22. It also helps estimate the severity of the child’s disorder.
The Role of the Physician: Prior to entering school, a child’s development and well-being has ideally been evaluated in a medical home. In some instances, a child may receive a diagnosis or a provider may have concerns about a child’s communication, social development, and /or behavior difficulties. A medical diagnosis does not automatically determine eligibility for special education services when the child reaches school age. However, a physician’s notes or diagnosis, provided by the family, may be considered by an IEP team when determining a child’s eligibility for special education services. Families are encouraged to share information between the physician and school personnel for releases to be compliant for HIPA and SERPA purposes. Editor’s footnote: Remind the families to have the IEP team read the physician note specifically; otherwise, it may not be considered in a child’s overall determination for eligibility for special education services. Pediatric Digest, Summer 2018 Page 23
The Individuals with Disabilities Education Act (IDEA) JOE DONALDSON, MA, NCSP | PRESCOTT, AZ The Individuals with Disabilities Education Act (IDEA) requires public education agencies to address a request for testing and, as warranted, conduct a review of existing data to determine the need to gather additional information to determine the presence of an IDEA defined disability. Informed parent/guardian consent is required before a public education agency can gather information that is reviewed by the required members to 1) determine the presence of an IDEA defined disability; and, 2) make a determination related to the need for specialized instruction. The Arizona Department of Education’s website cites over 200 public school districts and 400 charter holders (all are public schools) that are responsible for implementing the IDEA and the supporting state regulations. Each of these public education agencies and their respective governing boards adopts policy and procedures to afford each student access to a free appropriate public education (FAPE). The expectation, therefore, is the consistent implementation of federal and state requirements across schools by experienced special education directors implementing board-approved policies and procedures.
Given this expectation, the ________Unified School District or Charter School would welcome a letter from a medical provider requesting an evaluation, such as (A Child With A Learning Disability: Navigating School ... (n.d.) Retrieved from http://pediatrics.aappublications.org/content/114/ Supplement_6/1432:
“Dear (name of principal and/or special education director): I am requesting a full assessment of (child’s name) in all areas of this child’s suspected disabilities to determine whether he/she qualifies for special education services. (Enter the names of specific areas of concern or particular tests you consider important to the evaluation). I understand that the parents will be given an assessment plan authorizing this assessment within 15-days of your receipt of this request. I am also requesting that an IEP meeting be held within the time required by law….” However, the knowledgeable special education director from the ________USD or charter school, possessing a strong understanding of the IDEA with supporting special education practice, would clarify a few regulatory requirements before proceeding with the request for a full assessment. Essentially, clarification would emphasize the importance of pre-referral interventions before determining whether the learning needs of a student are consistent with a disability. The IDEA requires pre-referral intervention to address the datadriven educational needs of students. This process sometimes called the Child Study Team, determines the nature of the intervention to include documentation that the learning needs of a child were not the result of impaired vision or hearing; inadequate instruction; inadequate English language instruction; and, other social and economic circumstances. A letter from the physician or medical provider would either inform or initiate a referral to, the Child Study Team. The knowledgeable special education director would also clarify the timeline about the development of an assessment plan and subsequent IEP meeting.
Pediatric Digest, Summer 2018 Page 24
The letter from the physician implies that informed consent is established and the regulatory timelines are in force. Informed-consent suggests that the procedural safeguards have been explained to the parents/guardians and they have provided permission related to the assessment and evaluation process. Upon the receipt of the letter from the physician documenting a concern (and the child is not currently followed by the Child Study Team), the special education director must inform the parents/guardians within 10-school days (Arizona Administrative Code). The team will meet and determine the appropriate educational programming based on the letter from the physician, which in the example above, does not immediately include the development of an assessment plan nor an IEP meeting.
Seasoned special education directors, clinicians, teachers and medical professionals developed the attached letter with an emphasis on the role of the educational team, informed consent and to increase collaboration. This team recommends that the letter is used as part of the initial contact with the special education director/coordinator to increase collaboration and improve consistent implementation of the IDEA.
*Director of Education Sample Letter
Date: Month dd, yyyy Subject: Request for Meeting to Review Assessment and Medical Information
Dear Director of Education,
My patient
(first and last name)
the parent/guardian,
,
DOB (mm/dd/yyyy)
, was recently assessed and
(first and last names – could be two different names) who can be reached
at ___phone (two 10 digit phone numbers)
was interviewed to obtain developmental, family,
medical and diagnostic information. As a result of this assessment and interview, I am writing with informed consent of the parent/guardian to request that a meeting be held regarding this child and to review this data by the appropriate school team.
Based on the following medical concerns and/or diagnosis, these impairments have the potential to negatively impact performance in the educational environment. In discussion with the parent/ guardian, with respect to the presenting concerns and/or diagnosis, specific needs include (insert explanation of diagnosis or concerns—five line should be sufficient). Joe Donaldson, Nationally Certified I understand and have explained to the parent/guardian that this referral may result in the collection of additional data in consideration of special education placement or a 504 plan. Additionally, the following was reviewed: 1.) The decision to conduct an assessment to identify a disability requires
School Psychologist, Director of Special Education, Yavapai County Education Service Agency
parental participation; 2.) The school-based team, which includes the parents/guardians, determines the appropriate educational programming (this may range from a referral to the school’s Child Study Team to the development of an individualized plan); and 3.) The method to determine eligibility is a team process involving the collection and review of all relevant information.
Attached is a signed release to permit the electronic transfer of information, including medical and assessment reports to and from the school.
I look forward to our collaboration to address the educational progress of this child.
*Letter template to the left was developed in collaboration with special education leaders from public education in Yavapai County. Other template letters are available in AAP toolkits. Educators appreciate a letter from the provider and reference it for their need to
Respectfully,
review existing data.
(provider name and signature)
Pediatric Digest, Summer 2018 Page 25
Special Education and Related Services JOYCE MILLARD HOIE, MPA | PHOENIX, AZ What Physicians Should Know about Special Education Physicians often struggle when talking to parents and family members of children with disabilities when the conversation turns to school and educational services. Children spend anywhere from 6 hours (developmental preschool students, ages 3- 5) to 36 hours (High School students) per week in school, and it is common, even necessary, for physicians to have questions about a child’s progress in school and provide input about the educational services needed for the child. Here are some of the common issues that can intersect between health care and prescribed treatment and school teams and individualized education services.
Evaluation and Eligibility for Special Education and Related Services Although a child may have a disability as diagnosed by a physician or other health care professional, the Individuals with Disabilities Education Act (IDEA) describes the procedural regulations schools must use to determine whether a student is a child with a disability (IDEA Sec. 300.8) eligible for Special Education and
Joyce Millard Hoie, MPA, Former Executive Director, Raising Special Kids
Related Services. When evaluating a child suspected of having disability and needing Special Education, schools must use a variety of assessment tools and strategies to gather relevant functional, developmental, and academic information about the child, including information provided by the parent,… (n.d.) Retrieved from (IDEA Sec. 300.304(b)(1)). In short, a medical diagnosis alone does not entitle a student to Special Education services. School teams must carefully consider information provided to them by the parent including diagnostic information and data from evaluations conducted outside of the school when determining eligibility for Special Education. In order to fully meet the IDEA definition (and eligibility for special education and related services) as a “child with a disability,” a child’s educational performance must be adversely affected due to the disability. This determination is made by a group of qualified professionals, and includes the parent.
Special Education Planning and Provision of Supports and Services A student found eligible for special education is entitled to a Free and Appropriate Public Education (IDEA Sec. 300.17) that emphasizes services designed to meet their unique needs and prepare them for further education, employment, and independent living (IDEA Sec. 300.1(a) – Purposes. Once found eligible for special education, an Individualized Education Program (IEP) will be developed collaboratively by a team of people, the IEP Team, in a meeting. The Individualized Education Program describes the child’s current strengths and educational needs, goals for the child’s education over one calendar year, services and supports needed to achieve those goals, and the educational placement of the child. One way to think about the IEP is that it is a written agreement between the parent and the school that describes how the school will provide the child with a disability the Free and Appropriate Education he is entitled to receive under the Individuals with Disabilities Education Act. Specific supports and services will be listed in IEP, along with where the child will receive those services, how progress will be measured on the IEP goals, and how the child will be provided with access to the general education curriculum alongside their non-disabled peers.
Medical professionals can play a critical role as a member of an IEP Team with knowledge or special expertise of the child (300.321(a)(6)) by providing information on a child’s medical condition so that child’s health, well-being and safety in school environments are ensured. Schools will typically seek out the opinion of medical professionals and follow guidance in developing supports for administering medication, providing breathing treatments, feeding, proper body positioning, catheterization, and other needed medical supports that will be provided in a school setting. When determining appropriate supports and services to educate a child with a disability the IEP Team will examine data, including information from the parent, teachers and other individuals with knowledge of the child. The IEP Team uses this data and information to work toward consensus in the development of an appropriate educational program.
Recommendations for educational programming, made by medical professionals, such as small class sizes, 1:1 instructional assistant, ABA Therapy, specialized curriculum, and other specific classroom accommodations are taken into consideration by the IEP Team in the development of the child’s Individualized Education Program (IEP). Should a disagreement arise over the provision of services, or specific supports, a representative of the school district has the authority to make a decision and implement the IEP. Pediatric Digest, Summer 2018 Page 26
Parent Centers, Procedural Safeguards and Parent to
AzAAP Member Spotlight DR. GARY AUXIER SHARES HIS EXPERIENCE VOLUNTEERING
Parent Support Parents are afforded procedural safeguards under the IDEA and can learn
IN A SCHOOL-BASED HEALTH CLINIC
more about their rights and responsibilities at their State’s Parent Training and
Dr. Gary Auxier was born and
Information Center (PTI). Parent Centers are non-profit organizations, funded
raised in Arizona, graduated
under Part D of IDEA, typically staffed by parents of children with disabilities
from Northern Arizona
or individuals with disabilities, who provide high quality, relevant, and useful
University, then University of
information to empower parents to effectively advocate for their children.
Arizona Medical School,
Research consistently suggests that parents benefit from the commonality of
completed his residency at
experience shared when they have the opportunity to talk with another parent
Phoenix Children’s Hospital, and
of a child with a disability or the same medical condition, and in fact, Findings
is a general pediatrician
suggest (JEI, 1999, 22.3 pg. 224) that parents who use Parent to Parent
practicing at Gilbert Pediatrics
services for non-emergency help benefit from contacts with other parents by:
for more than 15 years.
Feeling better able to view their family and personal circumstances in a
“As far as getting involved with schools, most of us probably
more positive light, and
start by getting involved in our own kid’s classroom. Then the
Helping make progress on goals that are important to them.
classroom teacher finds out you're a doc, asks you to do
Feeling better able to cope with their child and family situation,
something for their class, and then word gets around you're
Next Steps, Tips and Suggestions
willing to do things, and they keep asking. In my case, I was
Refer families struggling with a new diagnosis, or new issue, for Parent to
volunteering for the Wilson School District in a clinic there, then
Parent support
found out there was one in my hometown (Chandler), so I
Contact Arizona’s Parent Training and Information Center to find out how
switched. The Chandler Care Center is a free clinic paid for
they serve families and how to refer
jointly by the Chandler School District and the City of Chandler.
Obtain consent from the parent to share information with the child’s IEP
Its a nice facility which screens the people in need of care for
Team
low-income eligibility and sometimes has funds available to do
Participate in IEP meetings to share treatment information for children
lab tests, X rays, or to pay for short courses of treatment. More
with complex medical needs
than an interest in school health, I just like seeing low-income
patients in a free clinic, and it happens to be run by the school. In general, the biggest barrier for pediatricians is not
EDITOR’S NOTE:
communicating or knowing how to communicate with the schools
I sincerely thank all of the authors for
and/or lack of involvement with schools. They need and
taking the time to contribute to this edition
desperately want our help; people get involved by just saying
of the Pediatric Digest. Also, thank you for
"yes" when they call. I feel like they need my help and
your patience as we pulled together the
involvement, and I give them my opinion; they treat me as the
expert advice needed to offer a balanced
expert and do what I recommend.”
perspective from the schools, psychologists and pediatric providers, as well as our community supports.
Cody Conklin-Aguilera, MD, FAAP, AzAAP Editor of Pediatric
Questions:
Digest, Secretary,
Questions and concerns pertaining to the
Board of Directors,
newsmagazine can be directed to Leadership@azaap.org or 602-532-0137.
Pediatric Medical Consultant, Children’s Development Center, Southwest Human Development
What Are Your Hobbies? “For fun, I play banjo, mandolin, and enjoy jamming with other musicians; I've been in several bluegrass bands. I also like outdoor activities such as skiing, rock climbing, spelunking, kayaking, backpacking. I'm a certified instructor in mountaineering, and wilderness medicine.”
Why is AzAAP Membership Important to You? “The AzAAP has helped with education, especially through Pediatrics in the Red Rocks. Being able to network with other pediatricians is very valuable, and keeping informed about local developments keeps me in the loop"
Pediatric Digest, Summer 2018 Page 27
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Save the Date! Speak Up for Kids: Heroes Unite! Saturday, October 13, 2018 | Heritage Square Families and the community are joining forces with Arizona's leading pediatricians to Speak Up for Kids, on Saturday, October 13, from 10am to 2pm, at Heritage Square in Phoenix. Speak Up for Kids: Heroes Unite! is a FREE outdoor event, open to the public, featuring a kid's zone with superhero-themed games and activities, superhero appearances, health fair exhibition and more! Families can come dressed up as their favorite superheroes, and have a great time for a great cause. For the reason every child deserves to be safe, healthy and protected, the event celebrates a day of awareness and encourages all Arizonans to participate in child advocacy efforts, be a voice for Arizona children and Speak Up for Kids.