Based on current research findings related to the effects of lead poisoning on the learning and behavior of individual children, schools have a responsibility to contribute to primary prevention and early intervention efforts to eliminate the occurrence of lead poisoning and address its effects on children.
The purpose of these guidelines is to clarify the role of schools in meeting the needs of children and families affected by lead.
It is critical that communities work together to:
- prevent lead exposure in children through elimination of lead paint in old homes, improvement of dilapidated housing, enhancing the nutrition status of at-risk children and parent education (primary prevention); and
- intervene rapidly when exposure has occurred to counteract potential toxic effects on neurocognitive development, learning, and behavior (early intervention).
While much work to prevent and to intervene early with lead poisoning in children has already been achieved through public health, housing, and medical officials, the role of schools in identifying and providing appropriate educational services to children who may have been exposed to lead has been less clear. The purpose of these guidelines is to clarify that role and assist educators in meeting the needs of children and families affected by lead.
What can schools do?
There are important steps that school districts can take to contribute to both primary prevention and early intervention efforts on behalf of children in their communities. Those steps are listed below. Specific details and issues related to each of these steps are then provided in individual sections that follow. In addition, two flowcharts are provided to visually demonstrate the process for steps 4 and 7 through 10; one is for preschoolers and the second is for students in kindergarten through Grade 12.
Develop school district policy and procedures regarding children who may be affected by lead.
Educate school personnel.
Collaborate with parents and community partners to educate families and students.
Immediately refer any child known to have exposure to lead to their medical provider and if appropriate, referral for housing assistance. Students with symptoms consistent with lead toxicity should be referred for urgent medical evaluation.
Use Child Find processes to locate, identify and refer as early as possible children with disabilities and their families who are in need of Birth-to-Three (Part C) or Preschool Special Education (Part B) services of the Individuals with Disabilities Education Improvement Act (IDEA).
Monitor children and young people birth to 21 who are at high risk for lead poisoning but do not have evidence of a BLL equal to or greater than 5 mcg/dL.
Obtain a lead history for all students ages 3–21 identified as having a BLL equal to or greater than 5 mcg/dL.
Develop a monitoring plan within a Scientific Research-Based Intervention (SRBI) framework, addressing the needs of all students ages 3–21, as appropriate, with a history of BLLs equal to or greater than 5 mcg/dL.
Refer preschoolers and young school-age children with a history of BLLs equal to or greater than 5 mcg/dL for enrichment opportunities as indicated.
Refer students, when indicated, to a Section 504 team or PPT for determination of a disability and eligibility under Section 504 of the Rehabilitation Act or the IDEA.
Step 1: Develop school district policy and procedures.
A policy addressing students affected by lead poisoning should briefly state a school district’s commitment to collaboration with parents and community partners to identify and intervene early with children who have been exposed to lead. Alternatively, if the district already has a policy on educating students with special health care needs, lead poisoning can be one of the health conditions that is addressed within the broader policy.
School district policy and procedures regarding students who may be affected by lead should include:
collaboration with community partners;
parent education strategies;
child find identification of children suspected of having a disability;
referral of identified students to the appropriate school team for monitoring;
referral of identified students for enrichment opportunities, lead screening, medical care, public health interventions and housing assistance; and
when indicated, referral for an evaluation to determine eligibility for special education or accommodations/modifications under Section 504.
Generally school districts already have procedures in place for Child Find, general education accommodations (e.g., individualized health care plans), SRBI, Section 504, and special education. Districts should review those procedures and ensure that they properly address the prevention, early intervention, or other needs of students with a positive history of lead exposure at BLLs equal to or greater than 5 mcg/ dL. A district can use the steps outlined in these guidelines to develop new procedures specific for these students or revise existing ones to include the recommended actions.
Step 2: Educate school personnel.
All members of a school team need to understand that:
- Lead poisoning, even at low levels of exposure (under 10 mcg/dL), may cause serious, permanent damage to an individual child’s developing brain and interfere with a child’s ability to:
Lead poisoning can be found in any child regardless of race, socioeconomic status or location of home.
Lead poisoning disproportionately affects urban and minority populations.
A history of lead exposure, even with BLLs levels at higher levels, does not, in an individual child, automatically indicate adverse effects.
Interventions to improve child outcomes should be multifaceted.
Prevention and early intervention strategies, such as enrichment, good nutrition, and effective parenting skills, can improve learning and behavior outcomes.
Educational interventions must be provided equitably within the context of applicable laws and regulations.
Many health and education providers today are not knowledgeable about the continuing existence of lead poisoning among children in Connecticut or the current research that provides evidence of neurotoxic effects of lead on the developing brain, even at low levels of exposure previously considered safe. It important for staff to learn about the current research, understand the potential for permanent harm in affected children, and recognize their responsibilities in the prevention, identification of children exposed to lead, and early interventions to counteract the harmful effects of lead poisoning.
Staff members also need guidance in understanding both the obligations and the limitations for addressing the needs of children with lead poisoning that federal law and regulation impose on school districts, particularly those related to discrimination and the education of children with disabilities. These guidelines are intended to help educators pursue best practice standards for educational interventions given those obligations and restrictions.
It may be helpful for school districts to identify a core group of professional staff (i.e., school nurses, school psychologists, school social workers and school counselors) to be responsible for providing consistent professional development programs within the district.
This core group must first gain knowledge about lead poisoning and a more in-depth understanding of the research and its implications for education than other staff may require. They can review the resources for educators discussed in section 3, use the PowerPoint provided in the Lead Action for Medicaid Primary Prevention (LAMPP) program, discussed in that section, and access some of the professional literature regarding the effects of lead poisoning on children.
Step 3: Collaborate with parents and community partners to educate families and students.
Schools should collaborate with parents and community partners to educate families and students about:
Primary prevention of lead poisoning and early intervention with those affected by lead’s presence in the environment require a broad community approach.
lead exposure prevention strategies;
sources of lead exposure;
the importance of enrichment and effective parenting; and
resources for education and intervention.
Primary prevention of lead poisoning and early intervention with those affected by lead’s presence in the environment require a broad community approach. Schools can contribute to primary prevention programs already established by local health departments and housing and medical providers funded to provide such programs in several ways. They can:
incorporate lead poisoning prevention information into health and science curricula for students;
collaborate with public health officials and pediatric medical providers in delivering educational programs for parents on lead poisoning prevention and effective parenting skills, and distributing educational information to families in the community;
alert staff, parents and community partners of known or potential lead hazards affecting the community or a segment of the community; and
identify children at high risk for lead poisoning and intervene through collaborations with public health officials before exposure occurs.
Schools should establish working relationships with providers of preschool enrichment opportunities, such as Head Start and School Readiness programs, to facilitate referral and placement.
Schools can — and are obligated to — contribute to early intervention efforts through Child Find activities, which are discussed in the next subsection. Schools should also establish working relationships with providers of preschool enrichment opportunities, such as Head Start and School Readiness programs, to facilitate referral and placement.
Step 4: Immediately refer any children known to have exposure to lead to their medical provider and, if appropriate, refer for housing assistance.Students with symptoms consistent with lead toxicity should be referred for urgent medical evaluation.
School personnel are often in a good position to identify children who may have been exposed to lead. When this information comes to their attention, school personnel should make a referral to the child’s medical provider and refer the family for housing assistance, if indicated. It is important to make these referrals as early as possible since lead poisoning often occurs with no obvious symptoms and, therefore, goes unrecognized.37
Signs and symptoms, if any, usually do not appear until dangerous amounts of lead have accumulated in the child’s brain and body. Severe symptoms of acute lead poisoning are rare, and are usually seen at levels of 70 mcg/dL and above. They require emergency intervention and include:
State law requires that health care providers consider blood lead testing for any child regardless of age with the following: unexplained seizures, neurologic symptoms, hyperactivity, behavior disorders, growth failure, abdominal pain, or other symptoms consistent with lead poisoning or associated with lead exposure; recent history of ingesting, or an atypical behavior pattern of inserting, any foreign object (even if the foreign object is unleaded) into a body orifice.
Children may show symptoms after extended periods of blood lead levels at lower levels. The following symptoms, while not specific to lead poisoning, may be indicative of lead poisoning, and should be considered by school nurses and other educators in assessing students who demonstrate:
loss of appetite;
learning difficulties; and
behavior problems, including hyperactivity and aggression.
Students with symptoms should be referred for medical evaluation and, if not already provided, a BLL screening.
Step 5: Use Child Find processes to locate, identify and refer as early as possible children with disabilities and their families who are in need of Early Intervention Program (Part C) or Preschool Special Education (Part B) services of the Individuals with Disabilities Education Improvement Act (IDEA).
Schools must actively use Child Find processes and collaborate with parents and community partners to identify, locate, and evaluate children from birth through age 21 who are suspected of having a disability or who have a known disability. This includes children who have a history of exposure to lead or a BLL equal to or greater than 5 mcg/dL. While not mandated by Child Find under IDEA or Section 504, school districts can also help identify children in the community at high risk for lead exposure and refer them for housing and public health assistance.
School districts are required under Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Amendments Act of 2008 and the IDEA of 2004 to actively identify children who may have a disability, as defined in the laws, and who may require accommodations in the classroom or special education. Because children who have BLLs equal to or greater than 5 mcg/dL may have sustained permanent brain damage, they should be identified through Child Find activities in collaboration with community providers such as Birth to Three, local hospitals, pediatric providers, public housing authorities, child care providers, school readiness programs, and nursery schools.
Among children from birth to attendance in kindergarten, Child Find activities may include:
identifying all infants, toddlers, and preschoolers with elevated BLLs equal to or greater than 5 mcg/dL;
monitoring those identified for early identification of neuropsychological and behavioral deficits or developmental delays that may develop, indicating the need for further assessment; and
referring families of those identified for assistance with parent education, housing, medical care, social services, and child enrichment opportunities, such as Head Start and School Readiness programs.
Child Find The Child Find process is used to identify, locate, and evaluate children from birth through age 21 who are suspected of having a disability or who have a known disability.
To attend early childhood programs in Connecticut, attendees must provide the program with the state mandated Early Childhood Health Assessment (“yellow” form) completed by their health care provider. This form asks for information on the child’s BLL screening results at one and two years and the health care provider must check “yes” or “no” to indicate if the child had a BLL equal to or greater than 5 mcg/dL. Community preschool providers, including public schools, should review those forms and identify children who should receive monitoring and referral services as identified above. That applies to all those meeting the current CDC standard of equal to or greater than 5 mcg/dL.
Infants and toddlers from birth to 3 years are automatically eligible for IDEA Part C early intervention supports when a BLL greater than 45 mcg/dL has been confirmed. Infants and toddlers with lower BLLs are eligible when two standard deviations (SD) below the mean is found in one developmental domain or a 1.5 SD below the mean is found in two or more developmental areas, whether or not the delay is due to lead exposure. It is critical to collaborate with Birth to Three providers to ensure a smooth transition to school services and to request any information they may have regarding a child’s BLL history, which may be shared with parent consent. This information can help Child Find teams to identify children with a history of lead exposure for monitoring and referral purposes as described above.
Early identification as well as Child Find efforts to identify students in kindergarten through Grade 12 also require collaborative parent and community partnerships since it may be parents, pediatric providers, hospitals, public health officials and housing authorities who can alert schools to a family that is newly exposed to lead (e.g., through building reconstruction or industry) or a school-age child who is newly diagnosed with lead poisoning. Educational programs for parents and periodic communications with community partners are useful strategies.
School nurses have a special role to play in the early identification and Child Find processes for students entering public schools, regardless of age. At entry into school, every child is required to have a health assessment documented on either the Early Childhood Health Assessment Record (“yellow”) form or the Health Assessment Record (HAR-3) (“blue”) form. The HAR-3 has been revised to ask health care providers to document whether a student has a history of BLL equal to or greater than 5 mcg/dL, rather than the student’s current BLL (see appendix A). Since school nurses should always review these forms for health information relevant to school attendance and learning, this is not an added burden for school districts and nurses. See the next subsection on obtaining a lead history for children with a BLL equal to or greater than 5 mcg/dL.
School nurses have a special role to play in the early identification of children exposed to lead and in the Child Find process for students entering public schools, regardless of age.
All school personnel must understand their responsibilities under the Child Find requirements. Any staff member who has a reason to suspect that a child may have been exposed to lead or has had elevated BLLs equal to or greater than 5 mcg/dL, should notify the appropriate school team, which includes any of the following:
- Child Find
- General education team
- IHCP (individualized health care plan) team
- Building pupil services team
- Section 504 team
- Planning and Placement Team (PPT)
The team may now ask the school nurse to gather more specific lead and other health history information before meeting to decide the next appropriate action.
Step 6: Refer and monitor children and young people birth to 21 who are at high risk for lead poisoning but do not have evidence of a BLL equal to or greater than 5 mcg/dL.
For children at high risk for lead poisoning due to their environment, but without evidence of a blood level at or above 5 mcg/dL, it is important to:
Ensure that they have been screened appropriately for blood lead. If not, referral for screening and medical monitoring is critical.
Refer, as appropriate, to social services, public health officials and medical providers for information regarding and assistance with prevention, housing, parenting, and financial, nutritional, and health care needs.
Monitor for screening results and changes in health status or living arrangements.
Re-refer as needed.
At-risk infants and toddlers (under age 3) are followed by their medical providers and may also be followed by local public health and social service officials.
Step 7: Obtain a lead history for all students ages 3-21 identified as having a BLL equal to or greater than 5 mcg/dL.
For all students ages 3–21 attending school and identified as having a BLL equal to or greater than 5 mcg/dL, the school nurse at a minimum should:
obtain a focused BLL history from the child’s pediatrician or health care provider (see appendix B for a sample Blood Lead History form); and
refer the child to the appropriate school team after obtaining the child’s complete lead history.
A history of a child’s blood lead levels over time is a much better indicator of overall exposure to lead than a single blood lead level (see Scientific Evidence in the Introduction). Even though the child may not show a functional deficit at an early age, research supports that educators should have a very high level of suspicion of brain damage from lead poisoning, including BLLs below 10 mcg/dL. Only individual assessment provides evidence of such effects and their specific nature in any given child. Deficits may persist38and not be evident until the child is older39 and learning tasks are more challenging. While it is neither required nor appropriate to evaluate every child who has been exposed to lead, it is reasonable and important to monitor them for early signs of a disability.
While it is neither required nor appropriate to evaluate every child who has been exposed to lead, it is reasonable and important to monitor them for early signs of a disability.
While it is neither required nor appropriate to evaluate every child who has been exposed to lead, it is reasonable and important to monitor them for early signs of a disability.
In the case of a child with a complex health or education history, it may be appropriate to request permission from the parent to complete a comprehensive health history and summary for the appropriate school team before referral is made to determine a child's eligibility for special education or accommodations/modifications under Section 504. A comprehensive health history includes the lead history. The school nurse, in consultation with the school nurse supervisor, school district medical advisor and other team members as appropriate, should make this decision.
For students in prekindergarten through Grade 12 attending public schools or private, nonprofit schools receiving health services through the public schools, the school nurse may obtain the information in any of the following ways:
the health care provider checks “yes” to the question of “history of elevated BLL” on the HAR-3 (“blue”) form;
the health care provider indicates a BLL at or above 5 mcg/dL on the Early Childhood Health Assessment Record (“yellow”) form; or
a parent or community partner reports that a child has a BLL equal to or greater than 5 mcg/dL.
Parental permission signed on the HAR-3 and Early Childhood Health Assessment Record form permits the school nurse to follow up with the child’s health care provider regarding details of the child’s history of elevated BLLs. Nevertheless, best practice is to inform the parent in advance of the nurse’s concern, plan to communicate with the physician, and anticipated next steps.
Two flowcharts at the end of this section demonstrate the process schools should follow for steps 7 through 10; one is for preschoolers and the second is for students in kindgarten through Grade 12.
In the case of a preschooler attending a program not receiving health services through the public schools (e.g., a community nursery school), parental permission signed on the Early Childhood Health Assessment Record form permits the program’s health/nurse consultant/coordinator to contact the health care provider for the lead history. As above, best practice is to inform the parent, in advance, of the consultant or coordinator’s concern, plan to communicate with the physician, and anticipated next steps. Next steps in this situation should include, with parental permission, sharing the information with the family’s local school district Child Find coordinator. The school district’s Child Find coordinator, preschool nurse, or other staff member should be designated to follow up on the history obtained and the need for a monitoring or other action plan.
Step 8: Develop a monitoring plan within a Scientific Research-Based Intervention (SRBI) framework, addressing the needs of all students ages 3–21, as appropriate, with a history of BLLs equal to or greater than 5 mcg/dL.
Students with a history of BLLs equal to or greater than 5 mcg/dL should be monitored as discussed above. The plan can be very simple, for example:
The general education team will meet to review the child’s progress on an annual basis, or more frequently (e.g., at progress monitoring intervals within the SRBI framework) should changes in health status, learning, or behavior occur.
These monitoring plans can be IHCPs, SRBI plans, student success plans, or if eligible, part of a Section 504 plan or IEP.
Step 9: Refer preschoolers and young school-age children with a history of BLLs equal to or greater than 5 mcg/dL for enrichment opportunities as indicated.
Since the research demonstrates that early enrichment and effective parenting skills can significantly enhance neuropsychological outcomes for students exposed to lead, school district teams should actively seek enrichment opportunities for these students. For preschoolers, districts can work with local program administrators of such programs, for example Head Start and School Readiness, to establish and facilitate placement of lead poisoned children in these programs. Young school age students with lead exposure may also benefit from enrichment through afterschool programs in the school district or community.
School teams should facilitate parental participation in educational programs related to enrichment activities at home and effective parenting skills when available.
Step 10: Refer students, when indicated, to a Section 504 team or PPT for determination of a disability under Section 504 of the Rehabilitation Act or the Individuals with Disabilities Education Act.
If at any point in the Child Find process, regardless of age or grade, a staff member or team suspects that a child may have a disability related to lead exposure, the staff member or team must refer the child to a Section 504 team or PPT for determination of eligibility under Section 504 of the Rehabilitation Act or the IDEA. The respective team must decide what evaluation is needed in order to determine eligibility and should follow established policy and procedures for making decisions regarding evaluation and eligibility.
If a 504 team determines that a child has an impairment (lead poisoning) and the impairment, without the use of mitigating measures, substantially affects learning, or another major life activity such as attention that in turn substantially limits learning, the 504 team should refer the child for evaluation under IDEA.
If the PPT is considering whether a child may be disabled due to lead poisoning, best practice suggests a two-step evaluation.40 The first step should be an evaluation to confirm deficient performance in the area where the deficiency is suspected. If a deficiency is confirmed, the PPT should consider if the child with a history of lead poisoning needs a comprehensive neuropsychological evaluation to look for other cognitive and functional deficits.41, 42 Brain injury from lead poisoning is similar to other types of brain injury where there is no single cognitive profile. Therefore, specific areas of the brain affected and the extent of the damage in any one area are variable child to child. The results of a neuropsychological assessment help the team to understand the discrete areas of the brain affected, including specific deficits, as well as compensatory strengths. This information helps the team to develop an appropriate IEP to meet the child’s individual learning needs.
Intelligence tests alone do not satisfy the requirements of a comprehensive evaluation and are not sufficiently sensitive to the effects of brain injury.
Intelligence tests alone do not satisfy the requirements of a comprehensive evaluation and, therefore, are unsatisfactory for evaluating children with lead poisoning. They are not sufficiently sensitive to the effects of brain injury. IQ or its equivalent is a single number that is determined based on the child’s overall performance on a battery of subtests that assess multiple and often unrelated functions. Brain injury, whether from trauma, oxygen deprivation or toxic exposures such as lead, frequently affects functioning in a limited number of neurobehavioral systems. Intelligence test batteries underestimate the effects of such injuries.43
It is for this reason that, once a deficit is identified in one area, consideration of a neuropsychological assessment of all areas is warranted. These areas include, depending on the age of the child:
- Executive function
- Working Memory Capacity
- Processing Speed
- Language - Perception
- Language - Reading
- Language - Speech Comprehension
- Language - Expressive Speech
- Language - Writing
- Perceptual - Motor
- Social/Emotional Behavior
- Adaptive Behavior 44
See appendix C for a sample neuropsychological assessment model for lead poisoning. This model is especially targeted for school-age students.
In preschoolers, comprehensive developmental assessment is the best method for identifying neuropsychological deficits.45This assessment should include the following domains:
- Measure of intelligence
- Executive functioning
- Working memory capacity
- Processing speed
- Language – perception
- Language – early reading
- Language – speech comprehension
- Language – expressive speech
- Language – early writing
- Social-emotional behavior 46
See appendix D for a sample assessment model for lead poisoning in preschool children. This model is very comprehensive. The PPT can use this model as guidance in developing an evaluation for an individual child.
Eligibility determination for special education must be made according to the evaluation results. Children with lead poisoning may be found eligible under the category “Other Health Impairment.” Lead poisoning is one chronic condition mentioned in the definition as defined in the federal regulations:
Other health impairment means having limited strength, vitality or alertness, including a heightened alertness to environmental stimuli, that results in limited alertness with respect to the educational environment, that—(i) Is due to chronic or acute health problems such as asthma, attention deficit disorder or attention deficit hyperactivity disorder, diabetes, epilepsy, a heart condition, hemophilia, lead poisoning, leukemia, nephritis, rheumatic fever, and sickle cell anemia; and (ii) Adversely affects a child’s educational performance.47
In addition, children may be found eligible under other categories, such as “Specific Learning Disability,” “Developmental Delay (3 through 5 years of age),” and “Speech or language impairment.” It is the evaluation results, rather than the history of lead poisoning per se, that should determine the most appropriate category for eligibility.
The following flowcharts visually demonstrate the process for steps 4 and 7 through 10; one is for preschoolers and the second is for students in kindergarten through Grade 12.
Flowchart 1: Managing Preschool Student with Lead Exposure
Flowchart 2: Managing K-12 Student with Lead Exposure