Comprehensive health assessments often are performed in school-based clinics or public health clinics by health professionals other than pediatricians. Pediatricians or other physicians skilled in child health care should participate in such evaluations. This statement provides guidance on the scope of in-school health assessments and the roles of the pediatrician, school nurse, school, and community.
- AAP =
- American Academy of Pediatrics
The American Academy of Pediatrics (AAP) has endorsed the importance of comprehensive periodic health assessments. The AAP also has endorsed the concept of the medical home,1 which refers to the belief that all health care for children and adolescents should be managed by 1 personal health care professional or group of professionals who assume responsibility for the ongoing care of the child. The medical home approach has been shown to improve compliance with health care recommendations and to lower the cost of health care.2 The AAP also recommends that each comprehensive periodic health assessment visit beginning at 3 years of age should include attention to school health issues. Whenever possible, these assessments should be provided by the child's primary care physician at regular health supervision visits and should be performed as recommended in the Guidelines for Health Supervision III 3 from the AAP. Additional visits may be necessary if circumstances suggest variations from normal.
Several different types of routine health assessments are performed in schools. In many schools, part of the core school health services nurses perform, often with the assistance of health aides, include mandated health screening for all students. This may include screening for vision, hearing, blood pressure, and scoliosis. If abnormalities are detected, students are referred to their medical homes for further assessment and treatment if indicated. Actions taken and recommendations for school intervention and/or follow-up must be conveyed to the school nurse so he or she can document the resolution of the situation, which initiated with the screening at school.
The school in communities where students do not have access to medical homes or a school-based health center may provide additional physical examination and assessment services. In these instances, a school nurse, public health nurse, nurse practitioner, physician assistant, or physician performs the school health assessment, often with the assistance of other allied health personnel. A pediatrician or other physician skilled in child health care should participate in the planning and supervising of these assessments. School districts that use school-based health examinations should contract with nearby pediatricians for consultation on the management of problems identified during the assessments.4 Each child should be examined individually (rather than in groups) to ensure adequate attention to individual problems and concerns and to protect confidentiality and the child's sense of modesty. Parents should consent to the school health evaluation and be present, particularly in the primary grades. Adequate time should be allocated to ensure that all elements of the assessment are addressed. Schools who assume the role of the medical home for their students must partner with a pediatrician, other licensed physicians, or hospital to provide after-hours and holiday emergency or urgent care.
ELEMENTS OF COMPREHENSIVE HEALTH EXAMINATIONS RELATING TO SCHOOL HEALTH
An assessment on entry into school should include a review of the medical history with attention to physical, emotional, or family problems that might influence school achievement. Previous participation in preschool experiences should be included in the history. The assessment should include a careful evaluation of language, motor, social, and adaptive development and immunization status.5 Private physicians or physicians and mid-level health professionals used by the school system should collaborate with designated school officials to design protocols. These protocols should be used to initiate appropriate referrals available in the school or the community and provide placement in the educational system as deemed appropriate by the findings of the medical history, physical examination, and developmental assessment.
Subsequent visits should include a history that focuses on new medical problems, medications, changes in the child's developmental and psychosocial status, and an update on school progress and problems. The frequency of subsequent health assessments will vary depending on the child's functional status but should be in compliance with the AAP-recommended periodicity schedule for child health supervision visits.
A complete age-appropriate unclothed physical examination should be performed by a physician or mid-level professional. It should include, but not be limited to, the assessment of height, weight, physical and sexual maturation, and blood pressure. A screening evaluation should be performed to evaluate visual acuity, auditory acuity, emotional maturity, language, dental condition, and motor skills.6 Any abnormal findings should be monitored by the physician.
In the United States, children of various ages participate in sports or physical education sponsored by the school. It is important for the health care professional to be familiar with the physical assessment and requirements to appropriately approve participation in such activities. This assessment should be combined with the health examination and interval history when possible, although it may be performed separately. In any case, the uniqueness of a detailed comprehensive physical examination that includes endurance and muscular assessment must be recognized. Specific descriptions of such an assessment are available.7 ,8
The health examination should identify specific health needs and problems that might require cooperation among community resources, and school officials may want to organize the community health professionals and community resources to integrate services available and provide easy access to these services. These services may support administration of medications, physical therapy, problems with access to buildings, anticipated absences, behavioral and emotional needs, special location in class (eg, for visual or auditory problems), or other conditions requiring the assistance of the classroom teacher or school nurse. Easy access to the services will become more important as increasing numbers of chronically ill or disabled students or students with special needs attend classes in their neighborhood schools. The frequency with which these issues are reviewed will depend on the student's specific needs. Direct communication among school personnel, parents, and the physician should occur to determine the requirements of children with special health care needs.
Anticipatory guidance for students and parents for physical fitness, nutrition, cardiovascular risk reduction, injury and violence prevention, sexual development and sex education, stress management, alcohol and other drug abuse, and tobacco use should be provided. Anticipatory guidance should be provided for parents about their role in promoting school achievement and learning as priorities in their child's life. Guidance also may be provided to assist parents in helping their child develop responsibility, independence, and self-reliance in the educational process.
THE SCHOOL'S ROLE
A well-organized system within the school that includes a comprehensive health record must be established for accumulating and recording current health information for each student. When a child changes schools, this information must be transferred to the new location. Information from health records should pass freely between the child's medical home and the school nurse and vice versa (with appropriate permission from the parents and/or adolescent). The school nurse and appropriate classroom teacher should review the child's health record, preferably before initiation of school year. For the student with chronic illness or with special health needs or for the child who must take medication during school hours, the school health record may require more frequent review. The school health record should include the following information: name, birth date, and sex of student; parent or guardian contact information; name, address, and telephone number of the child's primary health care physician; dentist and other medical specialists; immunization status and dates of immunizations; pertinent ongoing health problems; medications to be taken by the child; allergies; previous athletic injuries; and restrictions for athletics. Each school district should develop its own system for maintaining the confidentiality of the comprehensive health record. Access to this record should be based on the need to know and should require consent of the student, parent, or both.
A separate emergency information file available to all school personnel should be kept in the administration office and should contain the following information: the names, addresses, and telephone numbers (work and home) of parents or guardians; persons to contact in case of emergency; parental consent forms; and the names, addresses, and telephone numbers of physicians, consultants, dentists, and medical insurance carrier.
CONCLUSION AND RECOMMENDATIONS
In addition to providing a medical home, the pediatrician should be an advocate for students in the school setting and should promote effective communication among school officials, families, and the health care community. Collaboration among pediatricians, school nurses, and the community can ensure that children have access to appropriate and comprehensive screenings and assessments whether offered in the child's medical home or at the school site. The AAP recommends that:
All children should receive ongoing care in a medical home in a community practice, clinic, or school-based health center.
Core school health services including screening should be planned and implemented under the supervision of the school nurse and school physician when one is present and coordinated with the child's medical home.
Any additional health assessments performed in the schools where many students do not have medical homes should followGuidelines for Health Supervision III from the AAP.
On completion of the school health assessment, any positive findings requiring medical subspecialist or surgical subspecialist referral, should be performed in conjunction with the child's primary care provider.
Where schools assume medical care for students without medical homes, arrangements must be made to provide coordinated after-hours care for these children when school-based facilities or personnel are not available.
Herding of students for school physicals should be denounced because it provides quick superficial evaluation but may not address students complete health care needs.
Committee on School Health, 1999–2000
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
Evan Pattishall III, MD
American School Health Association
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
Linda Wolfe, RN, BSN, Med, CSN
National Association of School Nurses
Jerald L. Newberry, Executive Director
National Education Association, Health Information Network
Mary Vernon, MD, MPH
Centers for Disease Control and Prevention
Susanne Tropez-Sims, MD, MPH
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.
- ↵American Academy of Pediatrics, Ad Hoc Task Force on Definition of the Medical Home. The Medical Home. Elk Grove Village, IL: American Academy of Pediatrics; 1992:774
- ↵American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. Guidelines for Health Supervision III. Elk Grove Village, IL: American Academy of Pediatrics; 1997
- ↵American Academy of Pediatrics, Task Force on School-Based Health Clinics. AAP guidelines: school-based health clinics. AAP News. April 1987:7
- ↵Nader PR. Five years—entering school. In: Dixon SD, Stein MT, eds. Encounters With Children: Pediatric Behavior and Development. Chicago, IL: Year Book Medical Publishers; 1987:281–290
- ↵American Academy of Pediatrics, Committee on School Health. School Health: Policy and Practice. Elk Grove Village, IL: American Academy of Pediatrics; 1993:87–92
- ↵American Academy of Pediatrics, Committee on Sports Medicine. Sports Medicine: Health Care for Young Athletes. Elk Grove Village, IL: American Academy of Pediatrics; 1991
- American Academy of Pediatrics, Committee on Sports Medicine and Fitness
- Copyright © 2000 American Academy of Pediatrics