Significant Issues	Changes and Additions
Alignment with No Child Left Behind (NCLB)	• Ensures equity, accountability, and excellence • Applies NCLB highly qualified requirement to special education teachers
Provide earlier identification and eligibility	• Removes requirement that student must exhibit severe discrepancy between IQ and achievement for eligibility in learning disability category • Parent can initiate request for initial evaluation
Early Intervening Services (EIS) K-12	• Services for students not identified for special education, but who need academic or behavioral support to succeed in general education • Reduces need to determine student has a disability before providing support • Emphasis for services is on K-3
Private schools (Parent-placed child with disability)	• Must provide Child Find activities and fund proportionate amount for special education services as in public schools
School nurse services	• Expanded and renamed school health services and school nurse services • School nurse services are provided by a qualified school nurse • School health services may be provided by a qualified school nurse or other qualified person
Medication	• Prohibits schools from requiring medication (covered by the Controlled Substance Act) for attendance, evaluation, or for services in schools
Adaptive devices	• Must ensure that hearing aids are working properly • Must ensure that external components of surgically implanted medical devices (e.g. cochlear implants) are functioning adequately • Not responsible for postsurgical maintenance, programming, or replacement of the medical device
Individualized education program (IEP)	• Removes requirement of objectives
More relevant to student progress	• Must contain annual goals and description of how progress will be measured and reported
Reduces paperwork	• Team members may be excused if area is not being modified; parents and school agree in writing; written information is shared before the IEP meeting • May use alternative methods for IEP meeting, such as conference call or video conference • Minor changes can be made by conference call or letter, without meeting, if all parties agree
Time limits	• 60-day time line for initial evaluation starts when consent form for evaluation is signed or per state guidelines
Part C: Birth to age 3 services	• Must be based on scientifically based research • Recognizes significant brain development in first 3 years of life • Recommends training of personnel in emotional and social development of young children • States may opt to offer extension of Part C services to kindergarten age • Promotes collaboration among Early Head Start, early education, child care programs, and Part C services
New Child Find referral sources	• Expands program for referral sources to include homeless family shelters, clinics, and child welfare system • Children involved in substantiated child abuse and neglect or prenatal drug exposure (PDE) must be screened to determine need for referral to early intervention
Discipline for students with disability	• Serious bodily injury added to drugs and weapons as reason for 45-day removal from school

As more children and young adults with disabilities are integrated into community life, important implications affect nursing in all fields. An awareness of the effect of the disability on the child, family, and siblings enables the nurse not only to develop a special personal understanding but facilitates the acceptance of the individual into community and school settings.

The chapter concludes with specialized health care procedures. Many students, either in regular classrooms or special classes, require specialized procedures. The techniques used in a school setting frequently differ from those used in a hospital. The school nurse now may need to delegate certain health care procedures to licensed and unlicensed personnel and must provide teaching and monitoring for effective management. The nurse retains the responsibility for the delegated procedures. The needs of exceptional children are complex and require multiple treatment modalities and assistance in some form throughout their academic lives.

THE LAW

The right to a free and appropriate public education (FAPE) for children with disabilities from 5 to 21 years of age was established in 1975 with the enactment of PL 94-142, the Education for All Handicapped Children Act (EHA). This law addresses identification, evaluation, placement, and education of children with disabilities. In 1986, PL 99-457 amended EHA and provided a phase-in mandate for states to provide special education services to children ages 3 to 5 years. EHA provided grants for states to establish programs for children with developmental delays from birth to age 3.

The title of EHA was changed to the Individuals with Disabilities Education Act (IDEA) in 1990, and special education services for 3- to 5-year-olds were mandated in all states. In 1993, Part C of IDEA offered every state the opportunity to apply for federal funding for the implementation of a statewide, comprehensive, coordinated, multidisciplinary, interagency system of early intervention services for infants and toddlers with developmental delay and their families. These early intervention services for children from birth through 2 years of age are provided through various public agencies (e.g., Department of Health, Department of Education), private agencies, or any combination of public and private sources, depending on state laws and the state’s lead agency. The individualized educational program (IEP), birth to 3, is written as the individualized family service plan (IFSP). The bulk of this chapter applies to Part B, ages 3 through 21.

The first major revision of PL 94-142 occurred in 1997 with passage of PL 105-17, referred to as IDEA ‘97. The 1997 amendments provided a new emphasis on improving educational results for children with disabilities by ensuring they have meaningful access to the general curriculum through improvements in the IEP. A full educational opportunity goal was established to include students with disabilities in the general education reform efforts related to accountability and improvement of teaching and learning.

Major issues addressed by IDEA ‘97 include the following:

1. Focusing on the IEP as the primary tool for enhancing the child’s involvement and progress in the general curriculum. The IEP goals must relate more clearly to the general curriculum that children receive in regular classrooms.

2. Provision of regular progress reports to parents as often as reports are provided for other children.

3. Inclusion of students in state and district assessments, with accommodations and appropriate modifications if necessary, and establishment of alternate assessments as needed.

4. Inclusion of at least one regular education teacher on the IEP team. Decisions regarding participation by regular education teachers are made on a case-by-case basis.

These changes in IDEA establish high expectations for children with disabilities, and they exceed merely providing access to an education—they promote an optimal education. Parental involvement at all levels is encouraged, and full inclusion is emphasized.

I. Thirteen Disabling Conditions Defined in IDEA

A. Autism is a developmental disability that significantly affects verbal and nonverbal communication and social interaction, generally evident before age 3, which adversely affects a child’s educational performance.

1. The term does not apply if a child’s educational performance is adversely affected primarily because the child has an emotional disturbance (see paragraph D of this section).

2. A diagnosis of autism can be made in a child who manifests the characteristics of autism after age 3, if the criteria above are satisfied.

B. Deaf-blindness indicates concomitant hearing and visual impairments, the combination of which causes such severe communication and other developmental and educational needs to the extent that affected children cannot be accommodated in special education programs established solely for children with deafness or children with blindness.

C. Deafness is a hearing impairment so severe that the child is impaired in processing linguistic information through hearing, with or without amplification, and such impairment adversely affects educational performance.

D. Emotional disturbance^* means a condition exhibiting one or more of the following characteristics over a prolonged period, and to a marked degree, that adversely affects a child’s educational performance.

1. Inability to learn that cannot be explained by intellectual, sensory, or health factors.

2. Inability to build or maintain satisfactory interpersonal relationships with peers and teachers.

3. General pervasive mood of unhappiness or depression.

4. Tendency to develop physical symptoms or fears associated with personal or school problems.

5. Inappropriate behaviors or feelings under normal circumstances.

E. Hearing impairment means impairment in hearing, whether permanent or fluctuating, that adversely affects a child’s educational performance but that is not included under the definition of deafness in this section.

F. Mentally retarded indicates significantly subaverage general intellectual functioning concurrent with deficits in adaptive behavior manifested during the developmental period that adversely affects a child’s educational performance.

G. Multiple disabilities means concomitant impairments (e.g., mental retardation and blindness, mental retardation and orthopedic impairment), the combination of which causes such severe educational problems that the child cannot be accommodated in special education programs set up solely for one of the impairments. The term does not include deaf-blindness.

H. Orthopedic impairment means a severe orthopedic impairment that adversely affects a child’s educational performance. The term includes impairments caused by congenital anomaly (e.g., club foot, absence of limb), impairments caused by disease (e.g., poliomyelitis, bone tuberculosis), and impairments from other causes (e.g., cerebral palsy, amputations, and fractures or burns that cause contractures).

I. Other health impairment means limited strength, vitality, or alertness—including a heightened alertness to environmental stimuli—that results in limited alertness with respect to the educational environment. Must meet both of the following conditions:

2. Adversely affects a child’s educational performance.

J. Specific learning disability is defined as follows:

1. A disorder in one or more of the basic psychological processes involved in understanding or using language, spoken or written, that may manifest as an imperfect ability to listen, think, speak, read, spell, or do mathematical calculations. This includes conditions such as perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia.

2. The term does not include learning problems that primarily result from visual, hearing, or motor disabilities; mental retardation; emotional disturbance; or environmental, cultural, or economic disadvantage.

K. Speech or language impairment indicates a communication disorder—such as stuttering, impaired articulation, language impairment, or a voice impairment—that adversely affects a child’s educational performance.

L. Traumatic brain injury means an acquired injury to the brain caused by an external physical force—resulting in total or partial functional disability, psychosocial impairment, or both—that adversely affects a child’s educational performance. The term applies to open or closed head injuries that result in impairments in one or more areas, such as cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem solving; sensory, perceptual, and motor abilities; psychosocial behavior; physical functioning; information processing; and speech. The term does not apply to brain injuries that are congenital, degenerative, or caused by birth trauma.

M. Visual impairment including blindness refers to a visual impairment that, even with correction, adversely affects a child’s educational performance. The term includes both partial sight and blindness.

II. Components of IDEA

A. Those served are from birth through 21 years of age.

B. An effort must be made to screen and identify all children who are in need of special education and related services.

C. The environment must be the least restrictive. That is, children with disabilities are to be educated with children who are not disabled. Special education classes, separate schooling, or other arrangements that remove children with disabilities from regular education occur only when the disability is so severe that the student cannot be included in regular education, when provided with supplementary aids and services. In Part C, for children from birth to age 3, if children cannot be served in their natural environment, justification for a restricted placement must be stated on the IFSP. The natural environment is defined as anyplace a typical child of this age may be found (e.g., home, day care, Early Head Start, play group).

D. The program options within the special education system include the following:

1. Regular class with supplementary aids and services.

2. Related services.

3. Resource specialists.

4. Special day classes.

5. Special schools.

6. Nonpublic schools.

7. Residential facilities, hospitals, home.

E. Classroom placement is decided on an individual basis. Certain mandated attendees for the initial placement meeting include the following:

1. One member of the evaluation team.

2. A representative of the public agency.

3. The teacher.

4. A person knowledgeable about evaluation procedures and results.

5. One or both parents or a representative.

6. Other people as appropriate.

F. The Individualized Education Program (IEP) is a written plan for each student that guarantees appropriate services. Every special education student must have an IEP at least once a year. The IEP is developed by a team that comprises the following:

1. Parents of the child.

2. Not less than one regular education teacher if the child is, or may be, participating in a regular education environment.

3. Special education teachers or special education providers.

4. A public agency representative who has certain specific knowledge and qualifications.

5. An individual who can interpret instructional implications of evaluation results; may also be one of the other listed members.

6. Other individuals with knowledge or expertise regarding the child, chosen at the parents’ or educational agency staff’s discretion.

7. The child, when appropriate.

G. The IEP includes statements of the following:

1. Present levels of educational performance and how the individual’s disability affects progress in the general curriculum.

2. Measurable annual goals for meeting the student’s needs to enable the student to be involved and progress in the general curriculum.

3. Specific special education services, related services, and supplementary aids to be provided for the student; program modifications or supports to school personnel, so the student can participate in regular educational programs and activities as much as possible.

4. An explanation of the extent, if any, to which the child will not participate with nondisabled children in regular education.

5. Modifications needed to participate in state and district assessments; if not participating in a particular state or district assessment, a statement of why that assessment is not appropriate for the child, and how the child will be assessed, must be provided.

6. Statement of anticipated frequency, location, and duration of services and modifications.

7. Beginning at age 16, a statement of transition service needs a plan that promotes movement from school to postschool activities.

8. Statement of how the student’s progress will be measured and how parents will be regularly informed (e.g., report card).

H. Student and parent rights are defined.

1. Parents must receive detailed, written notice in their language whenever the school plans to change, or refuses to change, the identification, assessment, or educational placement of their child.

2. Parents have a right to one independent educational assessment at public expense each time the parent disagrees with an assessment conducted by the public agency. Parents have a right to review and inspect all educational records, give written consent to the assessment plan, give written consent before the child is placed, and refuse to consent to an assessment.

3. Evaluation and tests must be conducted in the student’s own language or mode of communication; a variety of achievement tests and teacher recommendations, as well as assessments of physical condition and social or cultural background, are used for placement procedures; regulations prohibit more than one reevaluation in a single year, unless both school district and parents agree; triennial evaluation may be waived when parents and public agency agree the reevaluation is unnecessary.

I. Regarding confidentiality, results of assessment data and placement must be kept confidential, and parents or guardians must have access to inspect and obtain copies of information regarding their child. An educational agency receiving federal monies must allow parents to inspect, challenge, and correct their child’s records. Students 18 years and older also have the same rights regarding their records. Parents are to be notified when unneeded records are to be destroyed.

1. Audiology.

2. Counseling services.

3. Early identification and assessment of disabilities in children.

4. Interpreting services.

5. Medical services (diagnostic and evaluation services only).

6. Occupational therapy.

7. Orientation and mobility services.

8. Parent counseling and training.

9. Physical therapy.

10. Psychological services.

11. Recreation, including therapeutic recreation.

12. Rehabilitation counseling.

13. School health services and school nurse services.

14. Social work services.

15. Speech and language pathology services.

16. Transportation.

K. Discipline and safety.

1. IDEA clarifies how school disciplinary rules apply to children in special education. IDEA specifically states that children who need special education must receive instruction and services to help them follow the rules and behave in school. The law recognizes that if students with disabilities bring illegal drugs or weapons to school, or if students cause serious bodily injury, schools have the right to remove the children to an alternative educational setting for up to 45 days. The law also acknowledges the right of schools to report crimes to law enforcement or judicial authorities. While under suspension or expulsion, the student should still receive special education services in an appropriate setting.

SECTION 504 OF THE REHABILITATION ACT OF 1973

This legislation defines disability more broadly than IDEA, which is limited to 13 categories of eligibility. Children with mental or physical disabilities that affect their ability to care for themselves, perform activities of daily living, or participate in educational activities may not be excluded from general school programs or denied special services because they do not have one of the eligible disabilities. Section 504 does not require a student to be enrolled in special education to receive related services. Accommodations and services must be provided to support the maximum educational opportunities possible (e.g., modifications in student assignments, physical adaptations of the school building, peer assistance).

Students are deemed eligible for services through an individualized evaluation by a multidisciplinary team. Students do not need an examination by a physician to qualify for Section 504, unless it is required by school administration. Under Section 504, a handicapped person means an individual with a mental or physical impairment that substantially limits one or more major life activities (e.g., breathing, self-care, walking, seeing, hearing, speaking, performing manual tasks, learning). Examples of students who may be eligible for Section 504 include those with attention-deficit disorder (ADD), diabetes, alcohol and drug addiction, asthma, obesity, and acquired immunodeficiency syndrome (AIDS).

Section 504 is a civil rights statute that prohibits discrimination on the basis of disability. States must comply with the regulations of Section 504 if they are to continue to receive federal financial assistance, but they do not receive federal funds for services provided under Section 504. The Office of Civil Rights (OCR) is responsible for monitoring compliance with Section 504 regulations.

WEB SITES

Building the Legacy: IDEA 2004 http://idea.ed.gov/

National Information Center for Children and Youth with Disabilities, State Resource Sheets http://www.nichcy.org/states.htm

Office for Civil Rights http://www.ed.gov/about/offices/list/ocr/index.html

Offices of Special Education and Rehabilitation Services http://www.ed.gov/about/offices/list/osers/index.html

SPECIALIZED HEALTH CARE PROCEDURES AND RELATED ADAPTATIONS

State, county, and district guidelines, procedures, and policies for administering specialized health care procedures (SHCPs) may vary but should include the following components:

1. HCP’s authorization for procedure.

2. Parents’ written request for the procedure.

3. Waiver signed by parent if procedure is to be performed by nondistrict personnel.

4. Universal precautions.

The main purpose of providing SHCPs in the school is to maintain the student in the school environment. Whether the SHCPs are performed in the student’s classroom or another location, one objective is to minimize disruption in educational programming. Other objectives are to address the privacy issues and health needs of the student and their classmates, to address the social and emotional effects surrounding exposure to procedures executed in the classroom, and to address the distraction from classroom work for all students.

When possible the nurse should:

1. Discuss with parents the possibility of doing the procedure before or after school.

2. Provide the procedure at the least disruptive time, if flexible schedule allowed.

3. Minimize the student’s time out of the classroom.

4. Have necessary equipment ready and medication available.

5. Use the procedure as an opportunity to teach health and secondary prevention.

The SHCP should be included in the student’s IFSP, IEP, IHCP, or Section 504 plan. The plan should reflect information in the SHCP, such as health treatment necessary during school, frequency, personnel involved, and the educational plan for school participation and optimal health. Include goals and objectives as appropriate.

ALLERGIES

Latex Allergies

Allergic reactions and sensitivity to latex proteins have risen dramatically during the past 15 years. The term latex is used here to describe products made from natural rubber latex, not synthetic latex (e.g., latex paint). Children who undergo frequent surgeries or bladder catheterization and individuals who regularly wear latex gloves are at the greatest risk for developing latex allergies. People with allergic rhinitis or other allergies also have a higher risk. Up to 68% of children with spina bifida and 8% to 17% of health care personnel have latex sensitivity, but the figure is less than 1% for the general population (American Latex Allergy Association, 2007).

The extensive use of latex gloves to prevent the spread of human immunodeficiency virus (HIV) and hepatitis B virus is believed to have contributed to the increase and awareness of latex sensitivity. This awareness has led to the education of health care providers regarding the potential health hazards and the necessity to minimize latex exposure.

Symptoms of latex allergy include flushing of the skin or an itchy skin rash, edema, watery or itchy eyes, hives, and wheezing. Anaphylactic shock can also occur. A more severe reaction is likely when latex contacts moist skin, mucous membranes, the airway, or bloodstream.

Cross-reactivity may occur in individuals with latex sensitivity, because they may react to certain foods with a similar protein (see Box 9-1). This cross-reactivity occurs when the immune system mistakes a similar protein or chemical composition for an allergen. Not all foods containing latexlike proteins affect everyone with latex allergies. An allergist can help identify foods and items that will cause an allergic reaction. Most common manifestations of latex-food syndrome are hives, facial edema, rhinitis, and conjunctivitis. Box 9-2 lists items that may contain latex.

Box 9-1 Foods with Latexlike Proteins