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Pediatricians and schools can be powerful partners in promoting children's health and academic success. Read on to become familiar with school health services and ways to work with school-based personnel to benefit your patients.
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Pediatricians and schools can be powerful partners in promoting children's health and academic success. Read on to become familiar with school health serviceswhich may be extensive in your communityand ways to work with school-based personnel to benefit your patients.
School health is at the dynamic intersection of education reform and child health. Schools recognize that students with unmet health needs are at risk of failing school. And pediatricians deal with complex medical and behavioral problems that could benefit from the support of school health programs. By entering into a partnership with schools, pediatricians can connect with community-based services and maximize their capacity to promote child wellness and academic achievement.
Consider the following scenarios. Are they familiar?
Seven-year-old Michael is brought to you for evaluation of hyperactivity. His teacher reports poor behavior and thinks he has attention deficit hyperactivity disorder (ADHD). Michael's mother is frustrated by his behavior, says he does not listen, and recalls that he has been difficult to manage since he was 5 years old. He is in special education and does not have symptoms of comorbid disease. Because ADHD is suspected, his mother and teacher fill out a Conners Rating Scale. Michael meets DSM-IV criteria for hyperactivity and impulsivity. His mother agrees to treatment with a stimulant. The teacher reports dramatic improvement in Michael's behavior on the Clinical Attention Problem Scale form. Michael's improved performance is noted on the annual special education review, and the school decides to move him to a less restrictive classroom.
David, a 10-year-old with moderate to severe persistent asthma, is supposed to take steroids twice a day but takes them only once daily. His mother reports that she is unable to supervise the morning dose because she leaves for work before her son awakens. The school nurse is enlisted to give the morning dose, and the mother continues to give the evening dose.
Sheila, an 11-year-old, is brought to the emergency department after a suicidal gestureshe tried to cut her abdomen with a pair of scissors during reading class. In the ED she is accompanied by the school social worker, who explains that Sheila is in fourth grade but does not read at grade level and is in a reading group with first graders. She was recently referred for evaluation for special education services. The clinical psychologist in the ED believes the girl is not a danger to herself and that her suicidal gesture was related to her sense of frustration and failure in school. She is discharged home with outpatient mental health follow-up and a letter from a mental health provider recommending that the school system better address her learning needs. This letter accelerates development of an Individualized Educational Program (IEP). Sheila will begin the next year in a special education classroom with children her age and ability level.
Although these children came to the attention of their primary care provider, school-based professionals were also involved in their care. Each of them benefited from the combined efforts of medical and educational professionals.
It is not unusual for school staff to become involved in medical issues. The author of one study estimates that 25% of children are at risk of school failure because of social, emotional, and health handicaps.1 School personnel address a wide range of issues in an effort to improve school performance, including ADHD, learning differences, communicable diseases, obesity, chronic disease, and medically fragile children. The list goes on: athletics, school attendance, tobacco use, drug use, mental health, abuse and neglect, suicide, violence prevention, safety, and pregnancy prevention, among others.
What school-based services do your patients receive? Have you worked with school-based personnel to manage your patients' health concerns?
School-age children make relatively few routine and acute visits to health-care providers, so there is limited opportunity to diagnose or treat health problems in office practice. Twelve routine visits are recommended during the first five years of life, and just 12 routine visits are recommended during the next 13 years.2
The school-age years are also an important time for prevention. During this period, children acquire attitudes, behaviors, and lifestyles that will have a lifelong impact on their health and well-being. The Centers for Disease Control and Prevention (CDC) Department of Adolescent and School Health (DASH) asserts that "six behaviors are responsible for most of the serious illness and premature death in the US:
Guidelines for Adolescent Prevention Services (GAPS) and guidelines for Medicaid's Early Periodic Screening, Diagnosis, and Treatment program (EPSDT) recommend addressing all these issues as part of routine health care. Time constraints on the pediatrician and the infrequency of visits may, however, limit his or her involvement.
School personnel, with their daily access to children, can complement a pediatrician's practice by monitoring known problems and uncovering new ones. School personnel are in an ideal position to impart health knowledge in a developmentally appropriate way and to reinforce positive attitudes and behaviors.
With regard to adolescent health issues, schools have additional advantages. School personnel (nurses, teachers, counselors, and coaches) rather than parents are often the adults that teens turn to for advice. These adults are also in the position to observe and address peer influences. Moreover, studies have shown that students frequently use school-based health centers (SBHC) located in high schools. In a review of the records of three SBHCs in Denver, approximately half the student body visited the health center at least once annually, and these teens averaged 5.5 visits per year. 4
Schools can also play a key role in the health care of uninsured and high-risk children. School health provides a safety net. Students have access to school health services regardless of their insurance status. School-based services eliminate scheduling and transportation difficulties. In addition, schools are often on the front line when it comes to supporting families, meeting social needs, and assessing for abuse and neglect. They can help families make connections with community resources that support children's development, health, and well-being.
Pediatricians realize that schools are a logical place to meet the health needs of school-age children. About 75% of pediatricians surveyed by the American Academy of Pediatrics (AAP) in 1994 felt there was great need for school health programming, indicated they were interested in becoming involved or increasing their involvement in school health programs, and wanted information on how to make a meaningful contribution given their limited time.5 The rest of this article provides background information for pediatricians interested in collaborating with schools to address pediatric health issues.
Most children experience school health through visits with the school nurse, sporadic classroom health lessons, a school lunch program, or perhaps a physical education class. There is, however, a shift in the meaning of school health represented by a growing interest by parents, educators, and the public health community in developing and implementing more comprehensive school health programmingprogramming that is proactive and can address more complicated health issues. This new type of school health has a broader scope and will require additional resources, as well as increased collaboration between health and school professionals.
Exactly what this more comprehensive vision of school health should look like is not universally agreed on and will differ by local regulations, available resources, and community priorities and values. Three models represent the scope of school health as it applies to the pediatrician: the coordinated school health program (CSHP), the previously mentioned school-based health center (SBHC), and the full-service school (FSS). These programs present different ways of envisioning and approaching school health but share common themes. All promote the assessment of community and school needs, expansion of school health services, and establishment of links with community-based agencies that can support referral. Moreover, these models are not mutually exclusive. For example a CSHP and a FSS could include a SBHC.
The coordinated school health program. This model, advocated by the CDC, identifies and integrates eight components: health services; health education; physical education; nutrition services; counseling, psychological, and social services; healthy school environment; health promotion for staff; and parent/community involvement (Figure 1).3 Because this model is implemented at a state or district level, its policies and programs can effect many schools. In an effort to explore possible operational models, the CDC provides 20 states with funds to implement CSHPs, develops and disseminates effective school health training curriculum and policy, and conducts the School Health Policies and Programs Study (SHPPS) to document which health practices and services are made available by states (see "A snapshot of school health practices nationwide"). Resources available on the Web describe a school-based and coordinated approach to nutrition, fitness, and asthma. (Web-based and print resources are listed in the box.)
School-based health center. This model provides primary and preventive care services for medical and mental health needs. Because each SBHC caters to the needs of its particular school population, services are not standardized. The School-Based Health Center Census conducted in 19981999 surveyed the 1,200 health centers across the nation and found that most provide some routine care, reproductive health services, mental health services, and prevention and health promotion services. The medical care is usually provided by a nurse practitioner. 6 SBHCs are not considered medical homes because children routinely change schools, which is incongruent with the concept of a medical home. 7 Revenue from insurance companies covers only about 20% of their operating budget.8 The majority of this budget comes from state and federal sources that are not always secure from one year to the next.
Full-service school. These schools inspire innovative and collaborative approaches to improving education, health care, and social service delivery in a community. In this model, the school becomes a community institution in which educational resources and medical, social, and psychological support services collaborate to promote the academic achievement, health, and well-being of children of the community. Ideally, all services are available on school grounds or in easily accessible locations so that the provision of services and collaboration between agencies is seamless.1
Many other models of school health exist, including a global model (see "School health is international,"). Some models incorporate elements of the three programs described above, others focus on particular components of health, such as mental health or healthy school climate. No one model fits all communities. The key for the pediatrician is to be aware of the existing model in his or her community.
Given that school health programming varies by location, providers must determine how they will access and use school-based services in their community. Generally, this means assessing the patient's school performance during each office visit, considering how the school experience affects known health issues, inquiring about school-based health services, and networking with the school nurse and other school-based professionals (Table 1). The following steps will improve communication and coordination of care between schools and clinics.
Assess for school failure. School failure is common: 30% of children do not graduate from high school in four years.3 Often, school failure is a symptom of a health-related problem. In some cases, special education services are appropriate, and pediatricians can guide families to obtaining access to individualized educational services.
Assess the effect of the school environment. Children spend at least six hours a day in school. It is important to consider how the school's physical environment affects known health issues. When treating obesity, for example, you should know if the patient participates in physical education or team sports and what meals and snacks he or she eats at school.
Ask about health services received in school. Many schools address known health problems and screen for unknown problems. Patients may not think to volunteer this information, so ask them if they receive counseling, medical screening, or treatment in school. Such screens alert us to patients' needs, as well as introduce us to available services and school health providerspotential partners in care.
Network with school health providers. Many school districts require that a child undergo a physical exam to enroll in school. This is an opportunity to identify yourself as your patient's primary care provider and provide contact information to the school. Meanwhile, make a list of the local schools and the school nurse in each building. Just as you might consult with a subspecialist, it is useful to consult the school nurse (or a school counselor or teacher if the school has no nurse) to assess progress and develop a care plan. School nurses welcome contact and guidance from a child's primary care provider. They can ensure that medicines are given, perform targeted physical assessments to monitor disease status, and reinforce education points.
School-based health care should complement, not replace, medical care provided by a primary care physician; this makes communication between the two health-care providers very important. The best way to ensure collaborative care is to contact the school nurseby telephone when you want to follow-up on how a patient is doing, in writing by indicating on school notes that you want to be contacted about any medical concerns.
Be sure to obtain permission from a patient's parent or guardian before speaking with any school personnel. Figure 2 is a sample permission slip. In the event that you have difficulty reaching the school nurse (some cover more than one school) or other school personnel, I recommend speaking with the school secretary, who should know how to reach the person you are looking for.
To meet the needs of your child __________________________________ (name), it may be necessary to exchange information with school-based personnel who also care for your child. Only information that is necessary to provide services related to ___________________(condition or health issue) will be released. This agreement will expire on ____________ (date).
You authorize the following organizations or people to exchange information with your child's physician, ________________________ (name).
Social service agency ____________________
Mental health service provider _________________
The information will be used to provide medical, educational, and social services in the best interest of your child.
Relationship to child
In some cases, the school system develops a more formal relationship with a physicianone in which the physician enters into a contract with the school to consult on health issues and develop policy. The role, responsibilities, and time commitment vary by the needs and resources of the school. Specific roles that the school physician may take on are listed in Table 2, available in the print issue (Adapted from the ?Template for Massachusetts School Physician/Medical Consultant Role,? developed by Massachusetts School Physician Committee in association with the Massachusetts Department of Public Health). The school physician may work closely with school nurses, social workers, health educators, mental health professionals, food service directors, principals, and athletic directors, depending on the specific issues they address.
The AAP has developed the "School Health Leadership Training Kit (at www.schoolhealth.org ) to guide pediatricians who want to become more involved in schools. The kit introduces candidate school physicians to strategies for approaching schools and writing school policy, relevant legal issues, the function of a school health council, and how to perform a community needs assessment.
Another way that physicians can become involved in school health policy in their community is to serve on the school board. Contact your local school system for information on how to do this.
When it comes to improving children's performance in school, pediatricians have a great deal to offer schools. When it comes to addressing the health-care needs of the school-age child, schools have a lot to offer pediatricians. Schools and pediatricians can be powerful partners who promote children's health and academic success.
The infrastructure to support this teamwork generally is underdeveloped, but the pediatric provider can take various actions to work with the schools. This relatively new area of pediatrics offers many opportunities for interdisciplinary collaboration that will grow as schools continue to link with community resources to help students succeed. Collaboration between the medical home and the educational home promises to greatly improve the health and well-being of school-age children.
1. Dryfoos J: Full-Service Schools: A Revolution in Health and Social Services for Children, Youth, and Families. San Francisco, Jossey-Bass, 1994
2. Committee on Practice and Ambulatory Medicine of the American Academy of Pediatrics: Recommendations for preventative pediatric health care. Pediatrics 2000; 105:645
3. Dukes McKenzie F, Richmond JB: Linking Health and Learning: An Overview of Coordinated School Health Programs, in Marx E, Wooley SF (eds): Health is Academic. New York, N.Y., Teachers College Press, 1998, pp 114
4. Kaplan DW: School-based health centers: Primary care in high school. Pediatr Ann 1995;24:192
5. Barnett S, Duncan P, O'Connor KG: Pediatricians' response to the demand for school health programming. Pediatrics 1999;103:e45
6. Schlitt J, Santelli J, Juszczak L, et al: Creating access to care: School-based health center census 1998-99. National Assembly on School-based Health Care. Washington, DC, 2000. http://www.nasbhc.org/1998_census_Text_Report.pdf
7. Committee on School Health of the American Academy of Pediatrics: School health centers and other integrated school health services, Pediatrics 2001; 107:198
8. Morone J, Kilbreth E, Langwell K: Back to school: A health care strategy for youth. Health Affairs 2001;20:122
Results of the CDC's School Health Policies and Programs Study (SHPPS), last performed in 2000, provide a picture of which health programs are in place in each state and throughout the country. This information is available at www.cdc.gov/nccdphp/dash/shpps/index.htm . Highlights of the national results include the following (percentages are rounded to the nearest whole number):
*73% of states have a person who oversees or coordinates school health services; 16% of schools have a full- or part-time physician who provides health services to students and 77% have a full- or part-time nurse.
*Just over half (53%) of schools meet the recommended nurse to student ratio of 1:750.
*88% of schools participate in the US Department of Agriculture (USDA) national school lunch program, and 64% of schools participate in the USDA school breakfast program.
*98% of high schools, 74% of middle schools, and 43% of elementary schools have a vending machine or school store, canteen, or snack bar.
*Half of all school districts have a contract that gives a company rights to sell soft drinks at schools in the district.
*80% of states require schools to teach health education.
*The effect of this mandate is limited by the small time requirement: 20% of elementary schools, 38% of middle schools, and 37% of high schools require a minimum of 30 hours of instruction per yearabout one class per week.
Counseling and psychological services
*77% of schools have a full- or part-time guidance counselor, 66% have a full- or part-time psychologist, and 44% have a full- or part-time social worker.
*71% of states require hearing screening; 71%, vision; 45%, scoliosis; 26%, height and weight; 20%, tuberculosis; and 18%, oral health.
*Just 8% of elementary schools, 6% of middle schools, and 6% of high schools provide daily physical education. Many schools, however, provide other forms of daily physical activity: 71% of elementary schools provide regularly scheduled recess.
*Almost all (99%) middle schools and high schools offer interscholastic sports.
Parent and community involvement
*In the year preceding the survey, 78% of schools provided families with information about the school's mental health and social service programs
*72% of schools provided information on the school health services program.
www.cdc.gov/nccdphp/dash Centers for Disease Control and Prevention school health home page. Includes national school health strategies, school health programs and policies database, healthy youth funding database, youth risk behavior survey results, further explanation of the coordinated school health model, and school health programming on asthma, nutrition, and exercise.
www.schoolhealth.orgAmerican Academy of Pediatrics school health resources for the pediatrician. Includes a leadership training kit to help pediatricians who want to become more involved with school-based health programming.
www.healthinschools.org/home.aspCenter for Health and Health Care in Schools home page. It includes an online journal with monthly updates of policy and research relevant to school health.
www.schoolhealth.infoAmerican Cancer Society runs this site, which gives community providers ways to get more involved in school health. A great resource on school health advisory councils.
World Health Organization School Health and Youth Health Promotion group site. Includes school health news, links to international school health activities, and information on health-promoting schools.
American Academy of Pediatrics policy statements
Full-Service Schools: A Revolution in Health and Social Services for Children, Youth, and Families, by Joy G. Dryfoos (Jossey-Bass, 1998)
Health is Academic: A Guide to Coordinated School Health Programs, edited by Eva Marx and Susan Wooley (Teachers College Press, 1998)
Schools and Health: Our Nation's Investment, by the Committee on Comprehensive School Health Programs in Grades K-12, Institute of Medicine, Washington, D.C. (National Academy Press, 1997)
The World Health Organization (WHO) advocates an international model of school health called health-promoting schools. Like the coordinated school health program, school-based health center, and full-service school models, this model recognizes the symbiotic relationship between health and learning and views schools as a logical place to address public health issues and focus prevention efforts. These schools "strive to provide a healthy environment, health education, school health services, along with school/community projects and outreach, nutrition and food safety programs, opportunities for physical education and recreation, programs for social support, counseling and mental health promotion."1 There are 300 health-promoting schools in Africa and 500 pilot health-promoting schools in central and eastern Europe. WHO supports this project with many global partners by providing training, financial support, and assistance in developing policy.
Healthy People 2010 lists 28 goals. Seven explicitly address school health issues and set specific and measurable objectives for improvement:
Increase the quality, availability, and effectiveness of educational and community-based programs designed to prevent disease and improve quality of life.
Increase high school completion rate.
Increase the percentage of middle, junior high, and senior high schools that provide health education to prevent health problems in the following areas: unintentional injury; violence; suicide; tobacco use and addiction; alcohol and other drug use; unintended pregnancy, HIV/AIDS, and STD infection; unhealthy dietary patterns; inadequate physical activity; and environmental health.
Increase the percentage of the nation's elementary, middle, junior high, and senior high schools that have a nurse-to-student ratio of at least 1 to 750.
Promote health for all through a healthy environment.
Increase the percentage of the nation's primary and secondary schools that have official school policies ensuring the safety of students and staff from environmental hazards, such as chemicals in special classrooms, poor indoor air quality, asbestos, and exposure to pesticides.
Reduce injuries, disabilities, and deaths due to unintentional injuries and violence.
Increase the percentage of public and private schools that require use of appropriate head, face, eye, and mouth protection for students participating in school-sponsored physical activities.
Reduce weapon-carrying on school property.
Promote health and reduce chronic disease associated with diet and weight.
Increase the percentage of children and adolescents age 6 to 19 years whose intake of meals and snacks at school contributes to good overall dietary quality.
Prevent and control oral and craniofacial diseases, conditions, and injuries and improve access to related services.
Increase the percentage of school-based health centers with an oral health component.
Improve health, fitness, and quality of life through daily physical activity.
Increase the percentage of the nation's public and private schools that require daily physical education for all students.
Increase the percentage of adolescents who participate in daily school physical education.
Increase the percentage of adolescents who spend 50% of school physical education time being physically active.
Increase the percentage of the nation's public and private schools that provide access to their physical activity spaces and facilities for all persons outside of normal school hours.
Promote respiratory health through better prevention, detection, treatment, and education efforts.
Reduce the number of school or work days missed by persons due to asthma.
Elisabeth Schainker, Linda Grant. Medical home meets educational home: Making the most of school health services. Contemporary Pediatrics 2003;3:55.