PEDIATRICS Vol. 106 No. 5 November 2000, pp. 1154-1155

AMERICAN ACADEMY OF PEDIATRICS:
Home, Hospital, and Other Non-School-based Instruction for Children and Adolescents Who Are Medically Unable to Attend School

Committee on School Health

	ABSTRACT

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The American Academy of Pediatrics recommends that school-aged children and adolescents obtain their education in school in the least restrictive setting, that is, the setting most conducive to learning for the particular student. However, at times, acute illness or injury and chronic medical conditions preclude school attendance. This statement is meant to assist evaluation and planning for children to receive non-school-based instruction and to return to school at the earliest possible date.

All school-aged children are entitled to obtain their education in a school setting. This recommendation exists not only because of legal mandates, but also because of the social and developmental advantages the school setting provides all children, including those with special needs.^1-3 Federal and state legislation clearly dictate that the most appropriate setting for education is the school; this setting should provide the least restrictive environment possible so children can achieve their maximum potential.^3-5

Homebound instruction is governed by federal and state laws, but implementation may vary not only from state to state, but also from one school district to another. It must be clear that homebound instruction is meant for acute or catastrophic health problems that confine a child or adolescent to home or hospital for a prolonged but defined period of time and is not intended to relieve the school or parent of the responsibility for providing education for the child in the least restrictive environment. This is defined by the Individuals with Disabilities Education Act (IDEA) of 1997 and Section 504 of the Rehabilitation Act of 1973.^5,6 The responsibility of public schools is further defined by the 1999 Supreme Court ruling in Cedar Rapids Community School District v Garrett F.⁷ Individual pediatricians and state chapters of the American Academy of Pediatrics (AAP) should make themselves aware of how these laws are being implemented in their local communities and states and use them when indicated to keep children in school.

Some children, by virtue of acute or chronic medical problems, are unable to attend school on a regular basis. The problems include a diverse set of maladies, such as recovery from surgery, trauma, prolonged recuperation from medical illness, chronic disease, and mental health conditions. Documentation of the student's inability to attend school should be provided by the primary care physician, who should serve as the student's medical home, providing comprehensive care in a setting of continuity in a culturally sensitive environment. This may require the assistance of the appropriate subspecialist, and, in the case of mental health issues, input from the psychiatrist, psychologist, or mental health counselor. The primary care physician must, in collaboration with the school district homebound education team, specify the anticipated duration of the homebound instruction. The need for homebound instruction should be reviewed at the end of that period.

When referral is made because of a mental health diagnosis, this referral should be made for a reasonable period, and psychiatric confirmation should be obtained. There should be evidence that counseling and/or medication is being provided. The rationale is that mental health issues may be less well-defined and more difficult to document. In cases in which there is a difficult diagnosis, such as chronic fatigue syndrome or fibromyalgia, without objective evidence of medical illness, an independent consult should be obtained before acceptance for homebound instruction.

Clearly defined school policies for non-school-based instruction should be established. Absence from school for any period will disrupt the educational process and should prompt the school administrator, school nurse, child's primary care physician, or child's parent to request non-school-based instruction. This non-school-based instruction should be considered as soon as possible for a child who may be absent for a prolonged period (eg, cystic fibrosis) or for a child repeatedly absent for brief periods (eg, hospitalization for acute asthma).^4,8 Information should be exchanged among the school, parents, and primary care physician to select the most appropriate type of non-school-based instruction for the child. For the hospitalized child, educational goals should be addressed in the discharge plan.

The following parameters should be considered during planning for a program of non-school-based instruction. First, non-school-based instruction should attempt, at a minimum, to mirror the progress the child would make in the classroom. Second, the pediatrician should assess whether the child and teacher place each other at medical risk (eg, contagious disease). Third, a parent or other responsible adult should be available during instruction. Finally, instruction hours and contacts should be based on the health status of the student and on available resources.

The school should identify a team to review the pertinent data for the child with the family and appropriate school administrators. This team could be linked to the IEP (individual education plan) team required by IDEA. Discussions should include review of relevant medical data, consideration of all educational options, a specific duration for services, and a plan for returning the child to the classroom. The decision for non-school-based instruction must be reviewed yearly by the school team with the goal of maintaining academic progress and returning the child to school as soon as possible.

Frequent or intermittent absences attributable to recurring illnesses, such as recurrent asthma or sickle cell vaso-occlusive crises, present a situation requiring frequent communication among parents, school administrators, and the primary care physician. This situation needs to be anticipated, and plans should be made, because there is often a delay between requests for and implementation of non-school-based instruction.

Other important issues include the following: the need to assess community resources to support return to school (transportation), the option of part-time school attendance, and in-school resources needed to allow an early return to school.

	CONCLUSION

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For children who are unable to attend school, education should be available in an alternative setting, such as a rehabilitation center, hospital, or the home. However, if special services, such as transportation, are provided, most children with medically fragile conditions or who require technological support can attend school. For these children, placement in the least restrictive environment that is medically feasible is the best way to normalize the learning environment.

Alternative educational settings are not intended to replace regular school-based instruction or relieve the school of the responsibility of providing meaningful program adaptations for children with special needs or medically fragile conditions. Pediatricians acting as child advocates by serving as school health advisors or as primary care physicians in the community must ensure that appropriate non-school-based instruction is initiated when necessary and that the child is returned to the regular school setting as soon as possible.

It is beyond the scope of this statement to discuss the complex range of federal, state, and local laws and systems for special education and related services for children and adolescents in public schools. Readers are referred to previous AAP statements for additional background material.^9,10

Committee on School Health, 2000-2001

Howard L. Taras, MD, Chairperson

David A. Cimino, MD

Jane W. McGrath, MD

Robert D. Murray, MD

Wayne A. Yankus, MD

Thomas L. Young, MD

Liaisons

Missy Fleming, PhD

American Medical Association

Maureen Glendon, RNCS, MSN, CRNP

National Association of Pediatric Nurse Associates and Practitioners

Lois Harrison-Jones, EdD

American Association of School Administrators

Jerald L. Newberry, MEd

National Education Association, Health Information Network

Evan Pattishall III, MD

American School Health Association

Mary Vernon, MD, MPH

Centers for Disease Control and Prevention

Linda Wolfe, RN, BSN, Med, CSN

National Association of School Nurses

Staff

Su Li, MPA

	FOOTNOTES

The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

	ABBREVIATIONS

IDEA, Individuals with Disabilities Education Act of 1997; AAP, American Academy of Pediatrics; IEP, individual education plan.

	REFERENCES

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1. American Academy of Pediatrics, Committee on School Health. Special education. In: Nader PR, ed. School Health: Policy and Practice. Elk Grove Village, IL: American Academy of Pediatrics; 1993:68-77
2. American Academy of Pediatrics, Committee on School Health. Children with chronic illness. In: Nader PR, ed. School Health: Policy and Practice. Elk Grove Village, IL: American Academy of Pediatrics; 1993:188-195
3. American Academy of Pediatrics. Proceedings from a National Conference on Public Law 99-457: Physician Participation in the Implementation of the Law. Elk Grove Village, IL: American Academy of Pediatrics; 1989
4. National Center on Educational Restructuring and Inclusion National study on inclusion: overview and summary report. NCERI Bull. 1995; 2:2
5. Individuals with Disabilities Education Act. 20 USC §1400 (1997)
6. Rehabilitation Act. Pub L 93-112 §504 (1973)
7. Cedar Rapids Community School District v Garrett F, 119 SCt 992 (1999)
8. Ushkow M Some children have occasional obstacles to learning (SCHOOL). Pediatrics. 1980; 66:333 [Abstract/Free Full Text]
9. American Academy of Pediatrics, Committee on Children With Disabilities The pediatrician's role in development and implementation of an individual education plan (IEP) and/or an individual family service plan (IFSP). Pediatrics. 1999; 104:124-127 [Abstract/Free Full Text]
10. American Academy of Pediatrics, Committee on Children With Disabilities Provision of educationally related services for children and adolescents with chronic diseases and disabling conditions. Pediatrics 2000; 105:448-451 [Abstract/Free Full Text]