The purpose of this document is to assist connecticut schools, regional educational service centers, or other settings where educational services are being provided to students with special health care needs, in identifying appropriate services and staff in the school setting, and to plan the support services necessary to ensure the safety and well-being of all students during participation in school activities. Clinical Procedure Guidelines for Connecticut School Nurses (Clinical Guidelines) is intended to provide a framework for the development of appropriate policies and procedures to meet the diverse health care needs of students in school settings. It is based on the laws and regulations that apply to education and on the laws, regulations, licensures, and professional standards of practice that currently apply to the practice of medicine, nursing and other health disciplines in Connecticut.
Within this document, the term “student” refers to all children and young people, ages 3–21 years old, who are entering or who are in educational programs. The term “special health care needs” refers to
those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally (McPherson, 1998).
The definition is broad in order to incorporate the entire range of students with special health care needs, whether physiological or psychological in nature, on a continuum from mild to severe and with actual or potential health service needs that must be addressed within school environments. While there is considerable emphasis in this document on those students with more severe physical health impairments, the philosophy and general guidelines are intended to apply to the entire spectrum of students with health service needs in the educational setting. Students with special health care needs that are psychological in nature include those who have mental, emotional, and behavioral problems, and require medication and/or special services, supports or programs to address those problems.
Whether a specific student’s health impairment and health service needs affect his or her eligibility for special education cannot be determined in general guidelines. Therefore, this document’s intent is not to identify who may or may not be disabled under either Section 504 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (IDEA), formerly the Education of the Handicapped. Related legal issues will be generally addressed in chapter 3, part a.
The population of children and youths with special health care needs is a diverse one, since their conditions vary widely according to numerous factors. These factors include, but are not limited to:
- specific diagnosis;
- age of onset;
- the natural course, duration, and severity of disease processes or extent of disability;
- chronological age compared to the child’s developmental stage;
- treatment regimens;
- family circumstances;
- impact on the child and family (functional, psychosocial, cultural, and financial)
- visibility of the condition;
- environment; and
- long-term outcomes (cure, stability, or deterioration).
While the specific diagnoses of students with special health care needs vary widely, they can be categorized by general type of disease or condition. These general categories, with examples of each type, are listed below. The list is not inclusive.
|Category of Disease or Condition||Examples|
|Chronic disease||Asthma, cancer, cystic fibrosis, diabetes, seasonal respiratory allergies, sickle cell anemia, inflammatory bowel disease|
|Chronic infectious disease||Hepatitis infections, human immunodeficiency virus HIV) infection|
|Congenital or acquired physical conditions||Congenital heart defect, spina bifida, cardiomyopathy|
|Psychological conditions||Childhood psychosis, major depressive disorder, bipolar disorder, oppositional defiant disorder, conduct disorder, attention deficit hyperactivity disorder|
|Acquired disability||Traumatic brain injury, lead poisoning, drug addiction|
|Severe acute illness, which may require complex medical care over several weeks or months||Nephritis, osteomyelitis, pneumonia|
All students with special health care needs should be assessed for issues related to psychosocial concerns. Students with special health care needs have a greater risk of problems with depression, anxiety, psychosomatic complaints, and low self-esteem. While some students with special health care needs will function well academically, some may have more difficulties meeting with academic success (Selekman, 2006, Chatterton, et.al, 2006, Henderson, 2006). Absenteeism, underachievement, and social adjustment problems are disproportionately higher in students with special health care needs. Some students fall into a pattern of school avoidance or school refusal, and the risks of teasing and bullying are high (Eiser, 1997).
For students with special health care needs to access their education and have a successful school experience, school district requirements may include:
- assessment and periodic reassessment of their health status and level of functioning on a periodic basis to determine what special services or program modifications they may need;
- policies that support close collaboration with families;
- safe professional practice;
- appropriate instructional programs;
- related services necessary to ensure successful functioning in educational settings;
- enhanced communication and collaboration with health and social service providers in the community;
- education of school personnel; and
- smooth interdisciplinary teamwork.
Connecticut’s public education system has the duty to provide opportunities for all students to achieve the statewide student goals (motivation to learn, mastery of the basic skills, acquisition of knowledge, competence in life skills and understanding society’s values) (CSDE, 2001). As such, children with health impairments share the following common needs to:
- interact with healthy children;
- identify and capitalize on their strengths; and
- mature to become independent, positive, productive, and socially responsible adults with the minimum disability possible.
In the early 1990s, the Connecticut State Department of Education formed a committee to develop guidelines for students with special health care needs in response to the increasing numbers of children with acute, long-term, and chronic health problems who attended schools in Connecticut. The original publication, Serving Students with Special Health Care Needs, was released in 1992. Its companion publication, Specialized Health Care Procedure Manual for School Nurses, was published in 1997. This publication, Clinical Procedure Guidelines for Connecticut School Nurses (Clinical Guidelines), is an update and merger of those two documents.
Across the nation, children with special health care needs are living longer, are able to live at home, attend school, and participate in their communities. Scientific and technological advances in the health care field have greatly enhanced the life opportunities of children with physical health impairments. It is no longer uncommon for children requiring special health care services and high technology procedures to be discharged home from the hospital, or not to be treated in the hospital at all, and to attend school. Some of these children are dependent on external equipment and support for survival. Similarly, changes in the treatment of children with emotional and mental illness have also resulted in fewer and shorter hospitalizations, increased outpatient treatment while the child is at home, and attending school. Frequently today, students with emotional and mental illness are hospitalized for only a short time and attend a partial hospital program during afternoon school hours. This may require an adjustment of a student’s schedule to provide supplemental tutoring for classes missed due to the hospital program. Children with special health care needs at the milder end of the spectrum may also require services or adaptations in school to minimize the negative aspects of their conditions or the treatments prescribed to control them.
Children and youths with special health care needs include those who are at risk for a chronic physical, developmental, behavioral, or emotional condition that requires services. The 2009–10 National Survey of Children with Special Health Care Needs found that 15.1 percent of the nation’s children met the definition of children with special health care needs (CCAMHI, 2012).
According to Selekman and McCormick (2006), nationally 7 percent of students with chronic conditions are receiving special education, 5.5 percent of students are identified under the label of Other Health Impaired (OHI), and Zirkle (2009) notes that in 2008, 1.2 percent of public school students had 504 plans with the majority of students having a diagnosis of attention deficit hyperactivity disorder (ADHD).
According to the Connecticut State Department of Education’s Special Education Fast Facts, in 2006-07, 11.2 percent of Connecticut students were in special education, which included 17.2 percent of students listed as OHI, with no breakout for ADHD.
According to the 2008 Special Education Parent Survey, in 2007-08, more than 90 percent of special education students in Connecticut attended public (89.8 percent) and private or parochial (1.4 percent) schools. Twenty-two percent of the students with special education needs are listed as OHI-Attention Deficit Disorder/ADHD and 4.1 percent are listed as OHI.
According to the State of Connecticut 2011 Health Services Survey Report, 88 percent of Connecticut school districts reported that over 167,000 students have one or more specific health care needs.
Meeting the Challenge
Advances in science and health care technology, in conjunction with society’s increased commitment to promoting optimal learning and development for all children, have increased the opportunities for students with special health care needs to achieve their individual goals. However, these advances also bring with them substantial challenges for families, schools, health care providers, communities, and society as a whole. To meet these challenges in an effective, efficient, safe and appropriate manner, it is crucial that experts in education, health, social services, law, financing, and municipal services collaborate with families and communities in identifying and promoting practices and programs that will enhance the quality of these students’ educational experiences and lives. A crucial step in meeting the special health care needs of students is the collaborative development, implementation, and evaluation of standards and guidelines to ensure the provision of safe and appropriate education and support services in school settings.
American Academy of Pediatric Dentistry. (2008). Definition of Special Health Care Needs. Retrieved on November 25, 2011.
Chatterton, J, Kaup, T, and Swanson, M. A. (2006). Diabetes Management in the School Setting.
Connecticut State Department of Education, Bureau of Special Education. (2007-08). Connecticut Special Education Parent Survey Summary Report.
Connecticut State Department of Education. (2001). The State Board of Education’s Position Statement on the Education of Students with Disabilities. Replaced in 2012 by the Connecticut State Board of Education Position Statement on the Education of Students with Exceptionalities.
Connecticut State Department of Education. (2009). Health Services Program Information Survey Report.
Eiser, C. (1997). Effects of chronic illness on children and their families. Advances in Psychiatric Treatment, vol. 3, pp. 204-210.
Henderson, J. 2006, Seizure disorder, in Selekman, J (ed.). School Nursing A Comprehensive Text. F.A. Davis, Philadelphia pp. 865-888.
McPherson M, Arango P, Fox H, Lauver C, McManus M, Newacheck PW, Perrin JM, Shonkoff JP, Strickland B. A new definition of children with special health care needs. Pediatrics. 1998;102(1 Pt 1):137-40.
Medical Home Portal. About Children and Youth with Special Health Care Needs (CYSHCN). Retrieved on February 2, 2012.
Selekman, J (ed.) (2006). School Nursing A Comprehensive Text. F.A. Davis, Philadelphia pp.757-780.
Selekman, J and Gamel-McCormick, M. (2006). School Nursing A Comprehensive Text: Children with chronic conditions. F.A. Davis, Philadelphia pp. 615-645.
Selekman, J. (2006). School Nursing A Comprehensive Text: Attention deficit hyperactivity disorder and learning disabilities. F.A. Davis, Philadelphia pp. 705-727.
The Child and Adolescent Health Measurement Initiative (CAMHI). Data Resource Center for Child and Adolescent Health. 2009/10 National Survey of Children with Special Health Care Needs. Retrieved on February 2, 2012.
Zirkle, P.A. (2009). History and Expansion of Section 504 Student Eligibility: Implications for School Nurses. Journal of School Nursing, Vol 25 pp. 256-260.