New Publication
Responsive Schools: Creating Management and Support Systems for Students with Asthma
Sam would rather stay home from school on Tuesdays. Now that it is spring, his physical education class meets outdoors for team games. The grass and blooming trees surrounding the field make him cough and wheeze. His classmates know that Sam can't run much because of his asthma, so he is always picked last for the team.
Introduction
The prevalence of asthma increased 74 percent among children ages 5-14 between 1980 and 1994. About 1 in 15 U.S. school children have asthma, and each year asthma accounts for 14 million missed days of school. Rarely is a child's absence caused by improper medication or poor medical treatment. The main culprit often is inadequate case management once the student is at school. And many parents keep their children home from school for that very reason: they are worried that the student's asthma will not be properly addressed, according to Howard L. Taras, Chairman of the American Academy of Pediatrics Committee on School Health.
This Web report follows a recent 160-participant teleconference among school and health professionals on "Improving Attendance, Improving Achievement for Students with Asthma," conducted by Urban Special Education Leadership Collaborative at Education Development Center, Inc., (EDC) in collaboration with the ILIAD IDEA Partnership, a project funded by the U.S. Department of Education, Office of Special Education Programs. Some students with asthma are served under IDEA 97 because of limited strength, vitality, or alertness. (Check out the Individuals with Disabilities Education Act (IDEA) Web site: http://www.ideapractices.org
Schools have had tremendous success with establishing asthma management programs. With an effective program, schools can reduce absences, reduce disruption in the classroom, and be prepared to address routine treatment as well as emergencies. Students who receive proper asthma care show improved grades and perform better in physician education classes, according to research from the National Heart, Lung, and Blood Institute (NHLBI). Effective asthma management also improves children's quality of life.
Everyone at school is a key player: the principal, school nurse, classroom teachers, physical education teachers and coaches, and students. Numerous resources exist to help them get started or improve their programs.
"We must think creatively about how to simultaneously meet a child's educational and health needs. It takes communication and collaboration among schools, health care professionals, the child, and families," said Judy Zorfass of EDC, an expert in the education of students with special needs.
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The Impact of Asthma on Schools and Students
- Low-income populations, minorities, and children living in inner cities experience disproportionately higher morbidity and mortality due to asthma, according to the Centers for Disease Control and Prevention (CDC).
- Students who are coping with asthma-related lack of sleep, medication side-effects, low self esteem, doctor/hospital visits, absenteeism, or going to the school nurse every day to take medications can experience greater difficulties with school work and peer relationships, according to the National Education Association.
- When children are absent, they often are unaware of which concepts and skills they are missing.
- If they have been up and coughing through the night, they might be too tired the next day to concentrate on academics.
- If they make frequent trips to the nurse's office, they lose valuable classroom time.
- If they have side effects from their medications-headaches, fatigue, hand tremors, stomachaches, confusion or memory loss-their school performance is reduced.
- When teachers and fellow students perceive children with asthma as being too vulnerable, these children miss opportunities to interact with and learn from peers.
- School buildings and environments are filled with asthma triggers, such as mold, chemicals, and germs. Twenty percent of U.S. public schools have indoor air quality problems, according to the General Accounting Office. (Many environmental contaminants, such as mold, airborne bacteria, or chemicals, cause other problems that damage student's performance, such as memory loss, confusion, or grogginess.)
- People with asthma have higher rates of depression, sometimes reported at rates of 20-50 percent. "Missing school days, not being able to play with other children, waking up in the middle of the night with an asthma attack, and going to the emergency room can lead to feelings of helplessness in children with asthma," according to the American Academy of Allergy, Asthma, and Immunology. Such feelings often result in poor self-care for asthma and a worsening of symptoms.
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The Federal Response
To help schools build and maintain an asthma management program, the Centers for Disease Control and Prevention (CDC) has outlined six key steps and drawn up actions for each:
- Establish management and support systems for asthma-friendly schools.
- Provide appropriate school health and mental health services for students with asthma.
- Provide asthma education and awareness programs for students and school staff.
- Provide a safe and healthy school environment to reduce asthma triggers.
- Provide safe, enjoyable physical education and activity opportunities for students with asthma.
- Coordinate school, family, and community efforts to better manage asthma symptoms and reduce school absences among students with asthma.
Strategies for Addressing Asthma Within a Coordinated School Health Program, which provides step-by-step guidance for each step, is available at: http://www.cdc.gov/HealthyYouth/CSHP/index.htm.
Visit http://www.nlm.nih.gov/hmd/breath/asthma.html for connections to dozens of online resources about asthma, compiled by the National Library of Medicine.
The Environmental Protection Agency has developed easy-to-implement, low-cost programs that schools can use to improve the school environment:
Indoor Air Quality Tools for Schools: Managing Asthma in the School Environment http://www.epa.gov/iaq/schools/asthma/index.html
Additional indoor air quality tools are available at: http://www.epa.gov/iaq/schools/tools4s2.html
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Asthma Case Management at a Glance
"The goal of every asthma management plan is to eliminate and prevent symptoms, recognize and respond to the earliest symptoms of an asthma flare, and know what to do in case of an emergency situation."
- Allergy and Asthma Network, Mothers of Asthmatics, Inc.
Every student with asthma will benefit from an action plan or a case management plan, that is placed on file with the school nurse or office. An effective plan addresses the impact of asthma on the child's education, environmental control, and medication. Asthma action plans are effective tools to help parents make strong connections with schools and to help schools develop a coordinated response.
Communications are essential, such as letters to parent/guardian, letters to health care professionals, and detailed case management flow sheets and detailed asthma reports.
Case management can include the following:
- Self-management programs can teach children and families about asthma prevention and treatment.
- Pediatricians and nurses can monitor adverse side effects of asthma medications to ensure that students are ready to learn.
- A multi-disciplinary team that includes the school nurse, guidance counselor, classroom teacher, psychologist, and administrator, can assess students' educational needs by looking at the students' work, examining test scores, and observing classroom behavior.
- These teams should differentiate between health and education accommodations. For example, carrying an inhaler to class is an accommodation for a health problem. Providing the student with a software simulation to develop math concepts at home, after a long absence, is an academic accommodation.
- Students with needed supports and adaptations should be encouraged to participate in physical, social, and educational activities to promote learning and build self-esteem and confidence.
- Older students can develop self-monitoring strategies to take responsibility for their own learning.
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How Schools Can Take Action in Asthma Case Management
What can schools do? How much is possible, given how many demands are placed on the academic day? Government agencies, state programs, and nongovernmental organizations have launched initiatives to help schools establish strategies that will prevent and treat asthma, while not intruding excessively into the school's primary task of education.
School Planning and Management
A number of agencies and organizations have developed comprehensive packages to help schools develop a multidisciplinary approach that involves staff at all levels, families, and students.
The National School Boards Association (http://www.nsba.org) has developed a comprehensive workbook that covers all aspects of school policies and practices regarding asthma management. The materials contain numerous tools, examples, and role-specific checklists. Asthma and Schools: Information and Tools for Making Informed Decisions About School Policies and Practices can be ordered by contacting NSBA at 1680 Duke Street, Alexandria, VA 22314-3493, 703-838-6722.
SchoolAsthmaAllergy.com provides accurate, current, and useful tools and information for all adults at school who care for children with asthma and allergies.
The National Asthma Education and Prevention Program of the National Heart, Lung, and Blood Institute Information Center - http://www.nhlbi.nih.gov/about/naepp - has developed a number of products for schools to use in asthma case management:
- Managing Asthma: A Guide for Schools
- Asthma Awareness Curriculum for the Elementary Classroom
- Asthma and Physical Activity in the School
- Making a Difference: Asthma Management in the School (video)
Curriculum and Education
Education about asthma can build students' confidence and encourage them to strive for the very achievable goal of symptom-free school days. In-class instruction in asthma management is especially helpful to younger students who may be adjusting to the condition and uncertain about how to manage it smoothly in school. Many curricula are available to help students with asthma and their teachers understand asthma and learn to make decisions about managing it.
Open Airways is an asthma management program for students ages 8-11. The interactive six-session program, developed by the American Lung Association (http://www.lungusa.org), aims to help children with asthma feel more confident about their care, feel healthier, and thus feel ready to learn at school. The program can be ordered by calling 1-800-586-4872.
The Asthma and Allergy Foundation of America (http://www.aafa.org) has an education program for middle-grades students, Power Breathing Program. A three to four session program, it focuses on the special challenges of teens. It can be ordered by calling 202-466-7643, ext. 230.
Policies
School asthma management efforts are strengthened by policies that support the need for basic measures such as the following, as identified by the National Asthma Education and Prevention Program:
- A smoke-free environment
- Availability of a school nurse
- Medication policies
- Emergency plan for urgent situations
- Staff development for all school personnel on all asthma-related issues
- Policies that support the development of a healthy environment
Such policies can help caretakers clarify their roles and responsibilities regarding children with asthma. To improve your school policies, services, and environment, see the National Heart, Lung, and Blood Institute's PowerPoint slide set on asthma at: http://hin.nhlbi.nih.gov/naepp_slds/menu.htm#schl.
Services
Schools with sufficient resources can offer a variety of services related to screening, assistance with medication, and treatment. Some schools have school nurses; others contract with a physician for a limited number of hours per month.
The Center for Disease Control and Prevention (CDC) has compiled information on "States that Require Districts or Schools to Provide Health Services by Type of Service" at: http://www.cdc.gov/HealthyYouth/shpps/summaries/health_serv/table3_2.htm.
Environment
School buildings contain many materials that can trigger asthma attacks, such as dust, mildew, carpeting, animal dander. Excessive temperatures or humidity, outdoor pollutants, and cleaning solutions are also present in many schools.
The Environmental Protection Agency has developed Indoor Air Quality Tools for Schools: Managing Asthma in the School Environment. Visit: http://www.epa.gov/iaq/schools/asthma/index.html.
Additional indoor air quality tools are available at: http://www.epa.gov/iaq/schools/tools4s2.html.
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Family and Community Professionals Who Play a Key Role
Parents, teachers, students, community members, and health care professionals each have a role to play in controlling asthma at school.
Many students will attend school even when their symptoms are intense, notes Karen Drezner of the Children's Health Fund in New York City. Her organization developed Stay Ahead of Asthma: A Survival Guide and Organizer for Parents (in English and Spanish) to help parents track their child's asthma and care. "Schools can really provide many opportunities for parents to be educated and can build bridges between families and the medical community," she noted. Visit: http://www.childrenshealthfund.org for a copy.
The Web site created by the Allergy and Asthma Network/Mothers of Asthmatics - http://www.breatherville.org/breatherville.htm - is designed by parents and offers suggestions and resources for action in many areas.
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Key Missteps to Avoid
Dr. Howard Taras of the American Academy of Pediatrics has worked in many schools providing consultation and assistance. School-based asthma control has much promise, he noted, while suggesting several key issues concerning physician/health care provider partnerships with the school system. Here are some missteps to avoid.
- Do not rely exclusively on parents for health information about the child. Many parents are not bothered if their child misses physical education and might underestimate the severity of asthma symptoms.
- Do not assume that doctors can insist that students come to see them.
- Sometimes schools are the first to notice that a child is overusing his or her medication in order to gain control of the asthma.
- Physicians face many barriers in trying to contact schools. Pressed for time, they often do not have information about the child's school, the correct phone number, or the person to call. Schools can help by providing community medical offices with a roster of schools and phone numbers.
- Health care professionals may not have the time or sufficient equipment to teach proper techniques with inhalers.
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Tools and Resources
Sample Forms for Schools
Numerous organizations and school districts have prepared information and materials on how schools can best manage asthma among students. One way to keep students with asthma healthy in school, and succeeding, is by creating and implementing a case management system that brings together general and special education practitioners, the family, school health professionals, and pediatricians. The San Diego City Schools has implemented numerous procedures and protocols to manage asthma. See the resources below.
- Asthma Action Plan
- Letter to parents regarding absences
- Letter to health care professionals regarding student's health
- Sample district asthma resource list
- Asthma Case Management Flow Sheet
- Asthma Student Roster
- Asthma Survey
- HealthLink Asthma Report
- Protocol for Asthma Management
- Recommended District Policy for Carpeting in Schools
- Administrative Procedure: Medication
Internet Resources
General
- American Academy of Pediatrics Committee on School Health: http://www.schoolhealth.org/section.html
- The Individuals with Disabilities Education Act (IDEA) Web site: http://www.ideapractices.org
- Strategies for Addressing Asthma Within a Coordinated School Health Program, which provides step-by-step guidance for each step, is available at: http://www.cdc.gov/HealthyYouth/CSHP/index.htm.
- For connections to dozens of online resources about asthma, check http://www.nlm.nih.gov/hmd/breath/asthma.html, compiled by the National Library of Medicine.
School Environment
- The Environmental Protection Agency has developed Indoor Air Quality Tools for Schools: Managing Asthma in the School Environment available at http://www.epa.gov/iaq/schools/asthma/index.html.
- Additional indoor air quality tools are available at http://www.epa.gov/iaq/schools/tools4s2.html.
Policies and Practice
- The National School Boards Association (http://www.nsba.org) has developed a comprehensive workbook that covers all aspects of school policies and practices regarding asthma management. The materials contain numerous tools, examples, and role-specific checklists. Asthma and Schools: Information and Tools for Making Informed Decisions About School Policies and Practices can be ordered by contacting NSBA at 1680 Duke Street, Alexandria, VA 22314-3493, 703-838-6722.
- SchoolAsthmaAllergy.com provides accurate, current, and useful tools and information for all adults at school who care for children with asthma and allergies. To improve your school policies, services, and environment, see the National Heart, Lung, and Blood Institute's PowerPoint slide set on asthma at: http://hin.nhlbi.nih.gov/naepp_slds/menu.htm#schl.
- The Center for Disease Control and Prevention (CDC) has compiled information on "States that Require Districts or Schools to Provide Health Services by Type of Service" available at: http://www.cdc.gov/HealthyYouth/shpps/summaries/health_serv/table3_2.htm.
- The National Asthma Education and Prevention Program of the National
Heart, Lung, and Blood Institute Information Center at the National
Heart, Lung, and Blood Institute - http://www.nhlbi.nih.gov/about/naepp -
has developed a number of products for schools to use in asthma case management:
- Managing Asthma: A Guide for Schools
- Asthma Awareness Curriculum for the Elementary Classroom
- Asthma and Physical Activity in the School
- Making a Difference: Asthma Management in the School (video)
Curriculum and Education
- Open Airways is an asthma management program for students ages 8-11. The interactive six-session program, developed by the American Lung Association (http://www.lungusa.org), aims to help children with asthma feel more confident about their care, feel healthier, and thus feel ready to learn at school.
- The Asthma and Allergy Foundation of America (http://www.aafa.org) has an education program for middle-grades students, Power Breathing Program.
For Parents and Community Members
- To improve your school policies, services, and environment, see the National Heart, Lung, and Blood Institute's PowerPoint slide set on asthma at: http://hin.nhlbi.nih.gov/naepp_slds/menu.htm#schl.
- Stay ahead of Asthma: A Survival Guide and Organizer for Parents (in English and Spanish) available at: http://www.childrenshealthfund.org.
- The Web site created by the Allergy and Asthma Network/Mothers of Asthmatics- http://www.breatherville.org/breatherville.htm - is designed by parents and offers suggestions and resources for action in many areas.
