Asthma WellnessKeeping Childrenwith Asthmain School and Learning

Asthma Management,Policies and Procedures

Liability & Litigation:A Legal Primer

Asthma & Indoor Air Quality (IAQ)

S t r a i g h t t a l k

By Paul D. Houston

School administrators know that numerous factors,from family support to language skills, academicreadiness to physical health, affect a child’s aca-demic success. Children cannot learn if they arehungry. They cannot learn if their teeth hurt.Children also cannot learn if they cannot breathe.

Here’s something that you may not know: asth-ma is this nation’s most common chronic child-hood disease, affecting more than five millionschool-aged children. Children miss an average of14 million school days each year because of asth-ma. Talk about a negative impact on academic per-formance.

Children spend nearly 40 hours each weekinside our nation’s schools. It is critical that schoolleaders be proactive about developing policies andprocedures that will keep children with asthma inthe classroom and about improving the quality ofthe air our children breathe.

This growing problem prompted the AmericanAssociation of School Administrators to undertakean effort to reduce the burden of asthma amongchildren and youth. AASA has embarked on anambitious five-year project, funded by the Centersfor Disease Control and Prevention, National Centerfor Chronic Disease Prevention and Health Promo-tion, Division of Adolescent and School Health.Within these pages, you will read about the impactof asthma on learning and achievement and ascer-tain specific strategies to identify and address this

issue in your school districts. You will also discov-er how to make the school environment safe for allchildren and to favorably position your districtagainst litigation.

Asthma is literally a life or death situation. Iknow, because one of my best friends died of asth-ma. Public education lost one of its greatest lead-ers when asthma took the life of Dr. RichardGreen, a former chancellor of the New York CityPublic Schools, during the height of his career.Now I’m dealing with this condition myself. Ideveloped asthma as an adult; doctors tell me ithas been triggered by the environment.

As superintendents or members of schoolboards, we know that we have an obligation todeliver every child an equal educational opportu-nity. We also understand our responsibility to carefor every child by responding to complaints,addressing health hazards within the schools,foreseeing potential problems and advocatingsolutions. When kids needed better nutrition sothat they could succeed, school administratorsstepped forward to advocate that school districtsprovide free and reduced breakfast and lunch pro-grams. Now it’s time for us to advocate forimproved indoor air quality and policies and pro-grams to better serve our school children withasthma. If we truly want our children to succeedacademically, then we’ll work to remove all thebarriers that prevent them from doing so. �

Paul D.Houston is executive director of the American Association of School Administrators.

In School and Healthy:A Critical Component of Academic Success

School Governance & Leadership

table of contentsSpring 2003

A School Board Publication of theAmerican Association of School Administrators

4 Cover Story: A Childhood Epidemic

6 Asthma Management, Policies and Procedures

10 Asthma & Indoor Air Quality (IAQ)

14 Liability & Litigation: A Legal Primer

f e a t u r e s

3

Straight Talk 2

Resources 16

Centers for Disease Controland Prevention (CDC)

CDC has developed the NationalAsthma Control Program with thegoals of reducing deaths, hospitaliza-tions, emergency room visits, school orwork days missed and limitations onactivity due to asthma. CDC also sup-ports the Americans Breathing EasierProgram, which focuses on enablingschools to implement effective inter-ventions, reducing classroom absencesfrom asthma, and building partnershipswith school districts and national asso-ciations.

This document was supported byCDC Cooperative Agreement NumberU58/CCU820135-01. Its contents aresolely the responsibility of the authorsand editors and do not necessarilyrepresent the official views of CDC.

Spring 20034

A Childhood EpidemicAsthma is the nation’s

leading cause of absen-

teeism due to chronic

illness, accounting for

more than 14 million

missed school days and

educational opportuni-

ties per year.

Moreover, asthma can

be deadly.

Asthma is the most com-mon chronic childhoodillness in the United

States today. Both the number ofchildren diagnosed with asthmaand the severity of asthma hasincreased rapidly in recentyears. Indeed, asthma hasreached epidemic proportions—affecting more than five millionchildren of school age. Asthmais the leading cause of schoolabsenteeism due to chronic ill-ness, accounting for more than14 million missed school daysper year.

This is a serious situation,concurs Dr. Beverly Hall, super-intendent of the Atlanta (GA)Public Schools. “A significantnumber of days lost due toabsences from school negativelyimpacts time on educationaltasks and academic perform-ance,” Hall points out.

Consider:

• Nearly one in 13 school-agedchildren has asthma (NCHS,1999). The cost in schooldays and missed educationalopportunities is estimated at14 million days per year(Mannino et al, 2002).

• In 1998, 3.8 million childrenunder age 18 suffered anasthma episode or attack(ALA, 2002).

• The estimated cost of treat-ing asthma in those under 18is $3.2 million per year(Weiss, Sullivan and Lytle,2000).

• Between 1980 and 1996, theprevalence of asthmaincreased 45 percent amongchildren ages 5-14 (Weiss,Sullivan and Lytle, 2000).

• Many districts have wit-nessed this increase firsthand. In the MinneapolisPublic Schools, asthmaaffects an average of 11

percent of their 49,000 stu-dents. In the HoustonIndependent School System,not only has there been anincrease in the number ofstudents with asthma, butalso an increase in the sever-ity of the asthma.

• Asthma is the third leadingcause of hospitalization in

School Governance & Leadership 5

Why School Leaders Are Concerned about Students with Asthma

children under 15 years ofage (Popovic, 2001). Theimpact is more classroomtime lost.

• The burden of asthma is dis-proportionately borne bypoor and minority children.For example, compared towhite children, black chil-dren are three times more

likely to be hospitalized andfour times more likely to diefrom asthma (Akinbami andSchoendorf, 2002).

• The number of childrendying from asthma hasincreased almost threefoldduring the past twodecades, from 93 in 1979 to266 in 1996 (CDC, 2002a).

It is important for school leadersto address asthma in a coordi-nated and proactive way.Schools can improve the lives ofchildren with asthma by ensur-ing the health of each child andby improving the “health” of theschool’s buildings and grounds.School policies and proceduresthat address these issues alsoprotect school districts frompotential litigation.

1. Asthma can be deadly. An asthma “attack” or episode can quicklyescalate and may result in death without prompt medical attention.

2. Most asthma episodes can be prevented. By combining a reduc-tion of environmental asthma “triggers” in the school’s internalenvironment with increased asthma awareness and proper med-ical management, most asthma episodes can be prevented. Goodcommunication between parents, the child’s physician and schoolstaff is also vital to successful asthma prevention. The result is abetter learning environment.

3. Healthy children learn better. Asthma affects a child’s perform-ance. Asthma can disrupt sleep, ability to concentrate, memory,and participation and can cause disruption to learning throughrepeated trips from the classroom to the school nurse to accessmedication (up to four times a day for some children.) Many schooldistricts do not have absentee data isolating asthma as a reason,but many can identify individual cases like the one cited by CedarRapids Supt. Dr. Lewis Finch: “A student in one of our middleschools had missed 33 days of school due to asthma by March oflast school year and was failing all but one class as a result.”

4. There are legal requirements that affect how schools dealwith students and staff who have asthma. Federal laws(Individuals with Disabilities Education Act [IDEA] of 1997 andSection 504 of the Rehabilitation Act of 1973) require that schoolsboth promote the health, development and achievement of stu-dents with asthma, where the disease interferes with their learn-ing, and remove “disability barriers” (e.g., poor indoor air quali-ty) that impede health, participation and achievement. The lawrequires schools and parents to work together as partners todevelop and implement health plans to protect the welfare ofthe child. �

The CDC has identifiedsix strategies foraddressing asthma aspart of a coordinated

school health program (CDC,2002b). Note that every strate-gy may not be feasible for yourdistrict. AASA encouragessuperintendents and boardmembers to join with staff, stu-dents and community membersto prioritize the strategies basedon your needs and the needs ofyour students. If your district isjust beginning to address thishealth issue, focus initially onchildren whose asthma seemspoorly managed as indicated byfrequent absences, trips to theschool nurse, emergency roomvisits and hospitalizations.

1. Establish management andsupport systems for asthma-friendly schools. Identify yourdistrict’s needs, designate ahealth coordinator, and developwritten policies and proceduresfor asthma education and

management. The NationalAsthma Education andPrevention Program (NAEPP)suggests that school districtsdevelop and implement district-wide guidelines and protocolsapplicable to chronic illnessesgenerally and specific protocolsfor asthma and other commonchronic illnesses of students. Dr.Howard Taras, medical consult-ant with the San Diego schoolsand chair of the AmericanAcademy of Pediatrics (AAP)Committee on School Healthagrees. “My recommendation isgenerally that we address allchronic illnesses that cause chil-dren to be absent. Let’s not makeasthma the disease du jour.”

2. Provide appropriate schoolhealth and mental health serv-ices for students with asthma.Make sure students with asthmahave an asthma action plandeveloped by a physician andprovided to the district by par-ents, ensure safe and immediate access to prescribedmedications, and use standardemergency protocols for stu-dents in respiratory distress. If

you need to send a letter to aphysician regarding an asthmaaction plan, you can use themodel “Dear Doctor” letter pro-vided by the American Acad-emy of Pediatrics (see page 12).In spite of the common practiceof maintaining zero-tolerancedrug policies in schools, limitingstudent access to life-savingasthma medications is a danger-ous decision. In Houston ISD,students are allowed to carrytheir own inhalers if the physi-cian says it is necessary; thusthe physician makes the medicaldecision about student responsi-bility. Dr. Don Kussmaul, super-intendent of the Dubuque (IA)Schools Unit 119, points out thatif a child needs an inhaler, it ismuch more useful in his or herpocket than at home or in theoffice.

3. Provide asthma educationand awareness programs forstudents and school staff.Ensure that students with asth-ma receive education on basicmanagement and emergencyresponse and provide schoolstaff and parents with the same

Spring 20036

Asthma Management,Policies and Procedures

What School System Leaders Can Do

Continued on page 13

T

Centers for Disease Control

and Prevention

Individual Student Asthma Action PlansEvery student with asthma needs to have an “asthma action plan” on filewith the school nurse—this is the key to asthma planning at school. Theaction plan, completed by the child’s physician, describes:

• Medication(s) taken—what,when, how, and possible sideeffects

• Whether the child needs tocarry his/her medications at alltimes

• Any specific allergies, andtheir symptoms

• Triggers for asthma symptoms

• When to take a peak flowmeasurement & what meas-urements indicate trouble

• What symptoms indicate a potentialemergency

• What steps to take in the event ofan emergency

• Parent and physician contact infor-mation & phone numbers

• Specific instructions regarding envi-ronmental conditions, e.g., childparticipation in field trips on highozone days

School Governance & Leadership 7

American Association of School Administrators(AASA)With support from the Centers for Disease Controland Prevention (CDC), National Center for ChronicDisease Prevention and Health Promotion (NCCD-PHP), Division of Adolescent and School Health(DASH), AASA has begun a five year project toreduce the burden of asthma among youth. Thiseffort to help school leaders take positive action forasthma wellness includes: helping the CDC developa national strategy; identifying school and communi-ty barriers, resources and best practices; creating aset of “Powerful Practices” and sharing these andother resources with school leaders through a vari-ety of dissemination vehicles. For information onPowerful Practices, call 703-875-0759 or e-mailtbrown@aasa.org. And through a cooperative agree-ment with the Environmental Protection Agency(EPA), AASA is also working to help schools adopt vol-untary programs that identify, monitor, and eliminatehazards to good indoor air quality (IAQ). The IAQTools for Schools Action Kit was developed to helpschool leaders assess potential problem areas with-in their buildings. Checklists are included for schoolstaff to begin initial steps to a common senseapproach that does not have to be costly. For moreinformation and a free kit, call 703-875-0731,eplater@aasa.org.

National School Boards Association (NSBA)The National School Boards (NSBA), through itsSchool Health Programs Department, makes avail-able information on asthma prevention and manage-ment. A "101" packet on Asthma in Schools, whichcontains facts about asthma, articles about bestpractices and policies, and references to additionalsources of information, is available at no charge. Inaddition, more customized and comprehensivesearches of the NSBA School Health ResourceDatabase can be requested. The School HealthPrograms Web site provides links to other Internet-based resources relevant to schools addressingasthma. NSBA's services can be accessed on theInternet at http://www.nsba.org/schoolhealth, by e-mail at schoolhealth@nsba.org, by telephone at 703-838-6722, and via fax at 703-548-5516. �

AASA and NSBA at WorkWhat is Asthma?Asthma is a chronic (long-term) lung condition thatcauses repeated acute episodes (or “attacks”) char-acterized by breathing problems such as:

• wheezing, • coughing, • chest tightness or pain, • shortness of breath, and• lack of energy.

These symptoms are due to inflammation and tighten-ing of the airways in the respiratory system. Asthmaattacks can be mild, moderate or life threatening.

It is not known precisely what causes asthma, butthe constant state of inflammation in the airways ofchildren with asthma makes them very sensitive toone or more environmental allergens or “triggers” thatcause further inflammation. Triggers can include dustmites, secondhand smoke, mold, animal dander, orpollution, as well as cold air, exercise, respiratoryinfections, flu and colds.

What sets off asthma in one part of the countrymay not be a problem at all in another. For instance,in the Shenandoah Valley where the Frederick County(VA) school district is located, newcomers are rarelyhappy to learn about the Valley Syndrome. “This is aglorious place to live,” says Supt. William Dean, “butthere are lots of oaks and maples and pines that giveoff allergens. We also have the agribusinesses, espe-cially spraying of pesticides on apple and peach trees.People who have never had allergies or asthmabefore often move here and get them. The valley syn-drome is hard on respiratory systems.”

In Houston, the hot, muggy climate leads to arecurring problem with molds, according to MattyeGlass, director of Health and Medical Services in theHouston ISD, who notes that last year’s severe flood-ing exacerbated the situation immensely. Along theMississippi, where East Dubuque Unit 119 schooldistrict is located, giant oaks add to a mold problemeach year.

Currently there is no cure for asthma. However,asthma management with medication and avoidingexposure to known environmental triggers as muchas possible allows those with asthma to lead normal,productive lives. �

Spring 20038

Cedar Rapids Community School District (IA)The Cedar Rapids (IA) Community School District hasparticipated in the Linn County Asthma ReductionCoalition since its inception in 2000. Last year theCoalition received a grant from Wellmark to implementa PAMPER (Partners for Asthma Management,Planning, and Educational Resources) program. PAM-PER comprises eight National Heart Lung BloodInstitute educational sessions in the home and/orschool setting, with the district’s school nurses provid-ing at least two of these visits at school for each childinvolved. Sessions reviewed symptoms and early warn-ing signs, use of medications and peak flow meter, anddeveloped and implemented the school asthma actionplan and emergency plan. Participants were studentswith asthma who had been hospitalized, or requiredemergency room visits, or multiple visits to theirhealthcare providers for asthma in the previous sixmonths. Superintendent Dr. Lewis Finch says thatbetween 2001 and 2002 absences from school or day-care had decreased from 126 to 55 for participants ofthe PAMPER project.

Minneapolis Public Schools The Minneapolis Public Schools (MPS), in partnershipwith the health care community, launched a three-yearasthma pilot initiative in eight schools that was so suc-cessful in its first year that it was expanded to all ele-mentary and middle schools in the second year.Working with the Healthy Learners Board, a partner-ship of 30 public and private health care providers andcommunity organizations, the MPS has been successfulin reducing asthma symptoms and absenteeism for stu-dents who visited the student health offices andreceived enhanced asthma care there, according toSupt. Dr. Carol Johnson. “We have seen improved atten-dance, a better job on the part of studentsto monitor their asthma situation,and better parent response toschool needs,” Dr. Johnsonnotes.

"In the Minneapolis PublicSchools, we know that some ofour students miss classbecause of asthma or otherrespiratory illnesses. Whenstudents are not in class, theyare not engaged and missvaluable learning time,"said Johnson. "If this collabo-

ration with families, schools and community clinicscan be successful at reducing the absenteeism of stu-dents with asthma, then we know these students willperform better academically. Attendance is the key tostudent achievement."

Evaluation of the pilot program showed that stu-dents in the pilot schools began visiting the healthoffice more for prevention and education than for asth-ma distress. Moreover, at the seven area clinics, theuse and sharing of written Asthma Action Plansincreased tenfold. “The increase in personalized asth-ma plans is an important reflection of communicationbetween schools, families and health care providers,”Johnson points out.

New York City Community School District 8(Bronx, NY)Hospitalization rates for children with asthma inCommunity School District 8’s PS 140 decreased signif-icantly (by 31.3 per cent) following initiation of a col-laborative program. (The Bronx has the highest asth-ma mortality rate in NYC across all age groups andleads the city in asthma hospitalization rates for chil-dren age 0-14).

The school district, whose superintendent is Dr.Betty A. Rosa, joined in a partnership with the healthdepartment’s Childhood Asthma Initiative and theHarlem Lung Center to mobilize the health care commu-nity and provide educational information to families andcaregivers. The initiative included extensive data collec-tion and analysis, development of an Asthma ActionPlan for each student identified with asthma, implemen-tation of family education workshops, and increased col-laboration with health care providers.

Central to this effort is the recognition that fami-lies, uncertain of housing, struggling

with poverty (84 percent of the chil-dren attending PS 140 are eligiblefor the Federal free lunch pro-

gram) and lacking sufficient infor-mation, can become confused andoverwhelmed when faced with asth-ma issues. Aimed with informationand clear messages of support fromthe school system and the commu-nity, the same families can becomeeffective advocates for their chil-

dren’s health and education.

Examples of Local School District Action

Continued on page 13

School Governance & Leadership 9

Spring 200310

Asthma & Indoor Air Quality (IAQ)

Children are especially vul-nerable to the adversehealth effects of indoor

pollutants and allergens—moreso than adults. Students withasthma are particularly at risk(GAO, 1995).

Some of the indoor allergensthat aggravate asthma are sec-ondhand tobacco smoke, mold,dust mites, cockroaches, animaldander, cleaning supplies andchemicals, pesticides, perfumesand paint.

The EPA has launched anational public education andprevention campaign targetingasthma. They provide informa-tion on indoor triggers and onactions that can be taken atschool or home to reduce expo-sure. To speak with a national

specialist, call 800-315-8096. Atthe request of the EPA, theNational Academy of SciencesInstitute of Medicine issued areport on the role of indoor airquality in the growing asthmaepidemic. The report, “Clearingthe Air: Asthma and Indoor AirExposures,” confirmed thatindoor pollutants are an impor-tant contributor to the asthmaproblem (National Academy ofSciences, 2002).

Asthma-friendly IAQ stepsinclude:

• Improving ventilation—throughout the buildings butespecially in laboratoriesand art rooms

• Removing sources ofallergens—mold, residue

from cockroaches and otherpests, animal dander, etc.

• Ensuring proper mainte-nance of heating and air con-ditioning systems

• Installing HEPA filters—whichtrap very small particles

• Planning for ongoingimprovement of the indoorenvironment—e.g., removalof carpet

Poor IAQ exacerbates seri-ous health problems like asthmaattacks. Recent research fromthe EPA shows that poor IAQreduces ability in mental tasksthat require concentration, cal-culation, or memory (EPA, 2000).

School Governance & Leadership 11

Financing Improved IAQThe expense and effort required to preventmost IAQ problems is much less than theexpense and effort required to resolve prob-lems after they develop. (EPA, 2000)

“Anytime we have dollars available formaintenance issues, we try to channel sometoward taking carpet out or replacing carpet…We regularly monitor the air quality, using acomputer driven system.”

—Dr. William Dean, superintendent,Frederick County, VA

While many IAQ solutions are low-cost orrequire no additional direct cost to schools, somebig budget improvements such as repairs to largesystems like roofs, flooring, windows, lighting, orventilation cannot be avoided. Possible fundingsources are:

• The school budget—the capital budget,the operating budget, money from grants,rebates, or fundraisers.

• Linking IAQ improvements to energy-effi-ciency upgrades—particularly upgrades tothe heating, ventilating, and cooling(HVAC) systems.

• Third-party financing and tax-exemptlease-purchase agreements.

• Individuals with Disabilities Education Act(IDEA) grants

“We just passed a $25 million code compli-ance bond and a $22.5 million Building andTechnology bond. We put in a Med-AssistSystem as part of the latter. It tracks air intake,preventive maintenance, etc. for the whole sys-tem. This allows us to find problems beforethey happen. We use IAQ in a partnership withour insurance company. It’s a pretty decentprogram.”

—Dr. Michael Frechette, superintendent,Norwich (CT) Public School

The EPA’s IAQ Tools for Schools is an excel-lent, results-oriented tool. With support fromEPA, AASA offers an internet presentation forschool leaders on financing good indoor air qual-ity. Call 703-875-0731 for more information. �

Q&A with Dr. Beverly Hall, Superintendent, Atlanta Public Schools

Q. How asthma-friendly is your district? A. Effective teamwork between school nurses, staff,students, families and health care providers facilitatethe district’s efforts to create a supportive asthmafriendly environment.

Q. What are some of your Best Practices thatmight be shared with other districts? A. The district’s “best practices” include ongoing annualcollaborative community-based partnerships with pedi-atric health care providers to host on-site health fairsand educational sessions to teach staff, students andparents about asthma.

Q. What prompted your district to address thisissue? A. The city of Atlanta experiences many “high ozone”days annually, which adversely affect students diag-nosed with asthma and exacerbates their symptoms.The high ozone days require precautionary measuresregarding outdoor activities involving student diagnosedwith asthma.

Q. Are students in your district allowed to carrytheir inhalers and use as needed?A. Students in the Atlanta Public Schools are allowedto carry their asthma inhalers and use as needed perwritten physician prescribed medication administrationorders. Physicians are requested to document thattheir client has received asthma education regardingthe safe self administration of prescribed medication.School nurses assess student’s asthma knowledgeand ability to safely self-medicate per written physicianmedication administration orders. The State of Georgiaalso passed legislation during the 2002 session author-izing the self administration of prescribed asthma med-ication by students diagnosed with asthma.

Q. Are there policies for allowing students to playoutside or participate in physical education activi-ties on high ozone/pollution/allergen days? A. While the district does not have policies to specifical-ly address outdoor activities during high ozone days orparticipation in physical education activities, such activi-ties are restricted on indicated days. Physicians providespecific instructions regarding participation in physicaleducation activities and precautions required for highozone days.

Spring 200312

Dear ______________________ (name or provider)

Asthma may be affecting your patient’s school performance.

We are writing about your patient, __________________________________ Date of Birth: ____________

The following information is being provided for your information and records.

❑ Missed ___ days in _____ period of time, possibly due to asthma.❑ Is not complying with asthma medication at school or the treatment plan you have provided.❑ Is not participating in P.E. because of symptoms related to asthma.❑ Visits school health office frequently because of symptoms related to asthma.❑ Has required emergency management of asthma (e.g.: 911, ER referral).❑ Our history and observations reveal that this student’s asthma severity has changed (see chart).

Days w/symptoms Nights w/symptoms PEF variabilitySevere Persistent Continual Frequent > 30%Moderate Persistent Daily > 4 per month > 30%Mild Persistent > 2 per week 3-4 per month 20-30%Mild Intermittent < 2 per week < 2 per month < 20%

The family was asked to schedule an appointment with you. Parents have provided permission for us to exchangeinformation (attached or shown below).

Please help with the following, either before or after the patient’s next appointment:❑ Please send us an “Asthma Action Plan” (attached form) so we can assist with your management plan.❑ Student has no Peak Flow Meter. Please prescribe one so that we may better assist with management.❑ Please prescribe a “Spacer.” This student’s technique with MDI was observed and is not adequate.❑ Requires an additional MDI ________ (medication name) at school for optimal availability/safety.❑ Please reassess this child and his/her current medical regimen. (See symptoms/severity above.)❑ Other: ____________________________________________________________

Please reach us if there are questions or concerns. Thank you!

____________________________________________ ___________________________________District Medical Consultant School Nurse (Printed and signature)

_________________ _________________ _______________ _____________School Phone Fax Best days/time

I permit my child’s doctor (named above) to communicate with school staff regarding my child’s asthma.Parent’s signature ________________________________________________ Date ____________

Sample "Dear Doctor" Letter

Source: American Academy of Pediatrics

Asthma Management, Policies & Procedures Continued from page 6

Examples Continued from page 9

Jackie Joyner-Kersee accepts thanksafter speaking to children with asth-ma at Parks Middle School in Atlanta.

type of information. Make surethat physical education teachersand coaches have adequatetraining—can they help preventan asthma attack and redirectstudent activities without stop-ping a child’s participation?

4. Provide a safe and healthyschool environment to reduceasthma triggers. Ensure asmoke-free environment at alldistrict-sponsored activities, onall district-owned propertiesand any form of school trans-portation. Promote good indoorair quality by reducing or elimi-nating allergens and irritants.Although school districts haveno control over the quality ofthe air outdoors, there arequestions that can provide youwith some policy guidance:Does the district have a policylimiting students' outdoor activ-ity on high ozone, high pollu-tion, high pollen and extremelycold days? What is the proce-dure regarding field trips sched-uled on such days? Have youconsidered equipping staffmembers on student field tripswith cellular phones or othercommunication devices in caseof asthma emergencies?

5. Provide opportunities forsafe, enjoyable physical activi-ty. Encourage full participationin physical activities when stu-dents are well, provide modifiedactivities as indicated by theaction plan, 504 Plan or IEP, asappropriate, and ensure that stu-dents have access to medica-tions before activity. With prop-er management, children withasthma can walk to school, par-

ticipate fully in school activitiesand potentially become a topathlete. Jackie Joyner-Kerseeand Greg Louganis have asthma,and at least one in six athletesrepresenting the United States atthe 1996 Olympic Games had ahistory of asthma (J Allergy ClinImmunol 2000; Vol. 106, No. 2: 260-266).

6. Coordinate school, familyand community efforts to bet-ter manage asthma symptomsand reduce school absencesamong students with asthma.Obtain written permission forschool health staff and physi-cians to share student healthinformation. It is important towork with local communities toeducate families about asthmasymptoms to help reduce stu-dent absences. Proactive lead-ership by superintendents andboards can create a coordinated,supportive environment forchildren with asthma. By work-ing together, and with otherschool district staff, familiesand the community, the impactof asthma on students can belessened. �

Frederick County (VA) PublicSchools“We only have 11,000 studentsbut a significant number ofthem report having asthma,says Frederick County Supt.Dr. William Dean. “When youtake a look at what asthma doesto a youngster, those kinds ofepisodes can’t help but erodeschool performance. It’s uncom-fortable, and it’s frightening forthem. That has to affect theirperformance.” “I would considerus asthma friendly,” he contin-ues. “Our school nurses keep aconfidential list—it’s sharedwith teachers on a need-to-knowbasis. We ask for principal inputyearly. On an annual basis wesend out physical forms and askfor an update on each child’sstatus. Each of our schools hasat least one peak flow meter.Also, we’re a non-smokingschool system. It’s not allowedeven on the grounds.”

Dr. Dean points out thatwhenever there are dollarsavailable for maintenanceissues, the school board tries tochannel some toward taking car-pet out or replacing carpet.Maintenance, such as replacingfilters, is strictly done. “We arecareful to ensure that there is achange of air throughout thesystem,” he notes “I’ve been insituations where the only airchange occurred when studentsopened the doors. We regularlymonitor the air quality, using acomputer driven system. Wehaven’t had any major inci-dents, but perhaps because thatis because we are so carefulabout the air quality in the firstplace.” �

School Governance & Leadership 13

School ResponsibilitiesUnder the Individuals with Disabilities EducationAct (IDEA) of 1997, schools are required to pro-mote the health, development, and achievement ofstudents with asthma. Asthma is classed as a dis-ability under the “Health Impaired” category ofIDEA, if it adversely affects a child’s educationalperformance or interferes with learning.

Schools are also required to remove “disabilitybarriers” under Section 504 of the RehabilitationAct (“504”). This law prohibits discriminationagainst those with disabilities in education oremployment. While having asthma is not consid-ered a disability in itself, school conditions (suchas poor IAQ) may be considered “disability barri-ers” which bar equal access for those with asthma.Schools are obliged to inform parents and studentswhom to contact if they perceive discriminatorysituations, conditions, practices or policies withinthe school. Further, “504” requires schools to fol-low certain procedures to protect the rights of par-ents, students, and school staff, and to ensure thatdecisions made regarding a child’s needs, and theirimplementation, are fair and appropriate. It stipu-lates that schools and parents should act as part-ners in the planning and decision making involvedin the child’s welfare.

Both IDEA and “504” outline student evaluationprocedures and stipulate the creation of individualhealth plans—an Individualized Education Plan(IEP) and a “504” accommodation plan, respective-ly. In addition to a student’s asthma-related infor-mation, these plans include environmental modifi-cations, physical education planning, and provisionfor studies during asthma-related absences fromschool. “504” ensures access to federally fundedservices for any handicapped person; IDEA pro-vides funds to help schools serve these studentswhen specific requirements are followed (IDEAgrants.)

Maurice Watson, an attorney with BlackwellSanders Peper Martin of Kansas City, MO, and aspecialist in education law, notes that in disabilitycases the courts increasingly look at the severity ofthe impairment. Thus, if the asthma can be reason-ably managed by medication, he continues, thatindividual might no longer have protection underIDEA and other federal statutes. “The court mightsay there is no “need” for further accommodation.

Spring 200314

Liability & Litigation

Twenty-one states currently have statewide policies or laws giving

A L e g a l P r i m e r

School Governance & Leadership 15

On the other hand, parents might respond that ifthere was higher compliance with IAQ, the childcould use less medication.”

A school’s best protection against liability is hav-ing policies and procedures in place and beingproactive. In the event of a lawsuit against the schooldistrict, it is important to be able to demonstratethat a school maintained its duty of care to studentsand staff by responding to complaints, dealing withproblems (establishing or disproving causationbetween, for example, poor IAQ and health com-plaints), and foreseeing potential problems.

Know the LawIn 1996, a court found the school's principal, guid-ance counselor, and the Orleans Parish schoolboard negligent in the death of an 18-year old NewOrleans schoolgirl, according to a report in theMay 29, 1996, issue of Education Week. CatrinaLewis died when a call to 911 was delayed becauseof efforts by the school counselor to contact hermother, as directed by the principal. Lewis alerteda school security guard when her inhaler was inef-fectual in controlling her asthma attack. The guardimmediately contacted the school principal whosaid that the girl’s mother had to be called (in histestimony he said he did not mean for her to becalled first, but to be contacted about the situa-tion.) The school counselor tried unsuccessfully toreach Lewis’ mother, and after 34 minutes it wasthe girl’s younger sister who eventually called 911.

The judge found that the principal and coun-selor violated a state law stating that school offi-cials have a duty to provide emergency medicalcare when a student requests it, and found theschool board negligent in both failing to provideadequate training for its employees, and in failingto have a clear policy on medical emergencies. Thejudge ordered the insurance companies for the twoschool officials to pay $1.4 million in damages toMs. Lewis' mother and two sisters, and the schoolboard to pay $200,000.

In 2002, a California jury unanimously awarded$9 million in damages (later reduced to $2.225 mil-lion on appeal) to a mother after the death of her11-year old son from an asthma attack at school.The school district was found guilty of negligencefor failing to warn parents of an unwritten schoolpolicy that would have allowed the boy to carry an

inhaler with him. Dueto a written school pol-icy stating that all med-ications must be storedin a specific place atthe school, PhillipGonzalez and his moth-er understood that hewas not permitted tocarry his inhaler. Theschool district con-tended that the regula-tion did not preclude astudent from carryingnecessary medication ifcertified necessary bya physician. However,in her testimony,Phillip’s mother point-ed out that the physi-cian’s authorization form supplied by the schooldoes not have a space for a doctor to indicate thatthe student should carry and/or administer his orher own medication. The court ruled that the dis-trict was liable for negligence due to the fact thatthe policy requiring medications to be stored atschool was written but the exception was not(Health and Health Care, 2002.) Twenty-one statescurrently have statewide policies or laws givingstudents the right to carry and use asthma inhalersat school.

Some UncertaintiesAttorney Maurice Watson points out that in termsof air quality issues, schools are not covered byOccupational Safety Health Administration (OSHA)standards, and it is uncertain what the legal obliga-tions might be in the future.

Mold in schools is emerging as a big problemfor school districts. Many schools across the coun-try have been closed for days, weeks and in somecases permanently, due to mold. And dozens oflawsuits have been filed already by teachers. Thewhole school district pays in such cases: studentsoften have to be accommodated on other campus-es, repairs are expensive and public (especially ifthe school is closed down), and someone may haveto foot the illness compensation bill. �

students the right to carry and use asthma inhalers at school

Legal checklist

• Know the law and be proac-tive in following it.

• Ensure you have policies inplace to avert medical emer-gencies and clear emergencyplans to deal with life-threat-ening situations.

• Inform parents of proceduresfor reporting complaints abouthealth or environmental issues.

• Respond to all questions orcomplaints—including thosefrom teachers—promptly andeffectively.

R e s o u r c e s

Allergy & Asthma Network Mothers of Asthmatics(AANMA)www.aanma.org, 1-800-878-4403. Information oncommunity awareness programs.

American Academy of Allergy, Asthma, andImmunologywww.aaaai.org, 1-800-822-2762. Physician referraldirectory, information on allergies and asthma forconsumers and health professionals.

American Academy of Pediatricswww.aap.org/, 1-847-434-4000. Information,resources, and publications on asthma; descrip-tions of grant projects.

American Association of School Administrators(AASA) Asthma Initiative.www.aasa.org/issues_and_insights/safety/asthma.htm, 703-875-0759. Powerful Practices forAsthma Wellness, IAQ Tools for Schools

American Lung Associationwww.lungusa.org, 1-800-LUNG-USA. Comprehensiveinformation on the prevention, diagnosis, manage-ment and treatment of asthma.

Resources

References

Strengthening the vital alliance between school board & superintendent

S C H O O L

Strengthening the vitalalliance between schoolboard & superintendent

Spring 2003 Vol. 5, No. 1

The American Association ofSchool Administrators publishes

School Governance & Leadership tofoster cooperation between school

superintendents and boards.

AASA PRESIDENTJohn R. Lawrence

AASA PRESIDENT-ELECTDonald Kussmaul

AASA EXECUTIVE DIRECTORPaul D. Houston

EDITORSharon Adams-Taylor

CONSULTING PUBLISHERDebbie Berger

The Unlimited Group

ILLUSTRATIONElizabeth Burnett

SchlegelBagel Design

This issue is made possible by a cooperative

agreement with The Centers for Disease Control and Prevention

Copyright © 2003 by theAmerican Association of School Administrators,

all rights reserved. School Governance &

Leadership (ISSN 1099-6379)is published quarterly by AASA,

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Arlington, VA 22203

Akinbami, LJ and KC Schoendorf. “Trends inChildhood Asthma: Prevalence, Health CareUtilization, and Mortality.” Pediatrics 2002, 110: 315-322.

Education Week. “Family Awarded $1.6 Million inAsthma Death at School,” May 29, 1996.

Gonzalez v. Hanford Elementary School District,Nos. F033659, F034555, (Super.Ct. Nos. 0031 & 1109)Reported in Health and Health Care in Schools, Vol3, No 4, June 2002.

Mannino, D.M, Homa, DM, Akinbami, CJ, Moorman,JE, Gwynn, C, Redd, S. “ Surveillance Summary,”March 29, 2002. MMWR 51 (#55-1): 1-13.

National Academy of Sciences (NAS) Institute ofMedicine Report: Clearing the Air: Asthma andIndoor Air Exposures, 2000http://books.nap.edu/catalog/9610.html.

National Center for Health Statistics, NationalHealth Information Survey, 1999.

National Institutes of Health, National Heart, Lung,and Blood Institute, National Asthma Education andPrevention Program (NAEPP), School AsthmaEducation Subcommittee. Asthma and PhysicalActivity in the School: Making a Difference, NIHPublication No. 95-3651, September 1995.

Popovic, JC. “1999 National Hospital DischargeSurvey: Annual Summary with Detailed Diagnosisand Procedure Data.” Vital Health Stat 2001; 13(151): 21, Table 10.

U.S. Centers for Disease Control and Prevention.“National Asthma Control Program: What Is the PublicHealth Problem?” Air Pollution and Respiratory HealthBranch, National Center on Environmental Health,2002a.

U.S. Centers for Disease Control and Prevention.Strategies for Addressing Asthma Within aCoordinated School Health Program, National Centerfor Chronic Disease Prevention and Health Promotion,2002b.

U.S. Department of Education. Planning Guide ForMaintaining School Facilities (DOE)http://nces.ed.gov/forum/pdf/Planning_Guide_For_Maintaining_Part1.pdf.

U.S. Environmental Protection Agency. IAQBackgrounder, Tools for Schools, 1999.

U.S. Environmental Prevention Agency. IAQ Tools For Schools.http://www.epa.gov/iaq/schools/asthma/index.html.

U.S. Environmental Protection Agency (EPA) IndoorEnvironments Division Office of Radiation and IndoorAir, Indoor Air Quality and Student Performance,August 2000, EPA 402-F-00-009.

U.S. General Accounting Office. (1995). SchoolFacilities: Condition of America’s Schools.GAO/HEHS–95–61. Washington, DC.

Weiss, K.B, Sullivan, S.D, Lytle, C.S. “Trends in the costfor asthma in the United States, 1985- 1999” Journal ofAllergy & Clinical Immunology, 2000; 106: 493-499.

Centers for Disease Control and Preventionwww.cdc.gov/nceh/airpollution/asthma/default.htm,1-888-232-6789. Information and statistical data onasthma; coordinated school health programs.

Environmental Protection Agencywww.epa.gov/iaq/asthma/resources.html. 1-800-438-4318. Resources on asthma and indoor air quality.

National Association of School Nurseswww.nasn.org, 1-877-627-6476. Asthma educationprogram for school nurses.

National Education Association HealthInformation Networkwww.asthmaandschools.org, 800-718-8387. Informationon asthma for teachers and administrators

National Heart, Lung and Blood Institutewww.nhlbi.nih.gov/about/naepp, 301-496-4236.Outlines diagnosis and management practices.Includes information for schools on asthma.

STARBRIGHT Foundationwww.starbright.org, 310- 479-1212. Asthma CD-ROMfor schools.