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Commentary From the Council on School Health

October 13, 2023

Commentary From the Council on School Health

The American Academy of Pediatrics (AAP) has a longstanding commitment to school health. What is now the AAP Council on School Health (COSH) began as a committee in the 1930s. COSH is dedicated to optimizing the personal health, academic achievement, and life-long success of children and adolescents. COSH seeks to promote sound school health policies and practices that ensure the health and safety of school-aged children and adolescents through policy, education, and advocacy. The vision of COSH is for all children and adolescents to reach their full academic potential in a safe and healthy school environment. Pediatricians work with other health care professionals, students, and schools to promote the physical, mental, and social well-being of all children and adolescents. The COSH executive committee sought insight from past leaders to identify the articles and policies published in Pediatrics that are most critical to achieving optimal school health.

Role of the School Physician

Marian Larkin, MD, FAAP1, Sara Bode, MD, FAAP2

Affiliations: 1Assistant Medical Director, High School Program, Office of School Health, New York City Department of Health and Mental Hygiene, New York City, NY; 2Medical Director, School Health Services, Nationwide Children’s Hospital, Associate Professor of Pediatrics, The Ohio State University College of Medicine, Columbus, OH

Highlighted Article From Pediatrics

One of the key public health lessons of the past few years has been a reminder of the vital importance of schools. Children need both physical health and educational success. Poor educational outcomes lead to poor health outcomes and vice versa. Pediatricians must engage in the school system at all levels to achieve their goals of a healthy pediatric population. The AAP policy statement on the Role of the School Physician1 is an overview of the wide range of needed roles and relationships for pediatricians in the school setting. 

As the AAP’s “COVID-19 Guidance for Safe Schools and Promotion of In-Person Learning2 points out, “Schools and school-supported programs are fundamental to child and adolescent development and well-being. Schools provide our children and adolescents with academic instruction, social and emotional skills, safety, reliable nutrition, physical/occupational/speech therapy, mental health services, health services, oral health care, and opportunities for physical activity, among other benefits. Families rely on schools to provide a safe, stimulating and enriching space for children to learn; appropriate supervision of children; opportunities for socialization; and universal support to cope with crisis and loss associated with the pandemic.”

With schools occupying such a vital role in children’s lives, it is logical that pediatricians would be actively involved in supporting school health and providing much-needed pediatric expertise for everything from managing children’s chronic health conditions during the school day to advising school districts on health policy and promotion. Indeed, the authors of the policy statement recognize that “the tradition of a school physician dates back to the 1800s,” with school physicians making significant contributions during, for example, the 1918 influenza pandemic and the polio vaccine campaign of the 1950s. 

Yet, as the authors point out, “physicians are not effectively and consistently involved in schools across the nation. As a result, US children have varying levels of medical support and safety, depending on the community in which they live.” Most children spend a significant amount of their time in school, while many may visit their pediatrician’s office once a year or less. The recent COVID-19 pandemic only further highlighted this gulf that often exists between schools and pediatricians practicing in the community.

All pediatricians can support their patients’ health and education by being knowledgeable about school health and how to work effectively with schools. Those serving as school physicians can advocate for a coordinated school health model to support all children’s healthy development and school engagement. The Whole Child Whole Community Whole School3 model described at CDC Healthy Schools is one example of such a model. School nurses are also a critical part of the school health team, as described in the AAP policy statement on The Role of the School Nurse in Providing School Health Services.4

Ten years after the publication of this policy statement, the need for school physicians continues—perhaps more urgently than ever as we strive to recover from pandemic school closures and address the additional impacts of social inequality, aging infrastructure, anti-vaccine misinformation, and the ongoing mental health crisis on our children’s health and development. Pediatricians make a real difference by getting actively involved with school health—and the policy statement on the Role of the School Physician1 provides an important foundation for those efforts.

References

  1. Council on School Health. Role of the school physician. Pediatrics. 2013;131(1):178-182
  2. American Academy of Pediatrics. COVID-19 Guidance for Safe Schools and Promotion of In-Person Learning. American Academy of Pediatrics; 2022
  3. Centers for Disease Control and Prevention. Whole school, whole community, whole child (WSCC). https://www.cdc.gov/healthyschools/wscc/index.htm
  4. Council on School Health. Role of the school nurse in providing school health services. Pediatrics. 2016;137(6):e20160852

The Link Between School Attendance and Good Health

Heidi Schumacher, MD, FAAP1, Danielle Dooley, MD, MPhil, FAAP2

Affiliations: 1Community pediatrician in Washington, DC, Executive Committee member of AAP Council on School Health; 2Medical Director of Community Affairs and Population Health, Child Health Advocacy Institute, Children’s National Hospital, Washington, DC

Highlighted Article From Pediatrics

Public education has been a bedrock of American life for generations. The commitment to educate the nation’s children has been rightly viewed as central to our national security and prosperity. Regular attendance at school has a direct relationship to academic performance, and improving school attendance has historically been the responsibility of the school system. However, data now show clear connections between academic attainment, graduation rates, and long-term health and life expectancy.

In this light, it is only natural that pediatricians would address acute and chronic medical conditions as well as the academic engagement and performance of school-aged children. The AAP 2019 landmark policy statement, “The Link Between School Attendance and Good Health,” provides an important addition to the scientific literature regarding the connections between health and school attendance and the critical role that pediatricians can and should play in partnership with schools to support their patients’ academic success.

A 1965 piece published in Pediatrics by Harold H. Mitchell, MD, entitled “School Medical Service in Perspective” illustrates the early days of such partnerships. Dr. Mitchell describes that the early focus of school health was on the management of communicable disease and the provision of health screenings but notes the importance of “interprofessional teamwork” and the “new kind of skill which grows out of the co-operative working relationships of medicine and education.” He also describes a burgeoning awareness of the role of social determinants of health and education, including poverty, which continue to impact children today.

Over the last 75 years, enrollment in the public education system has increased significantly. In 1940, only 24% of Americans 25 years and older had a high school diploma or higher,1 compared to 91% in 2021.2 Further, the average number of days in a school year has risen significantly over the same time period. In 1869-1870, an average school year was only 132 days long,3 compared to 180 days now.

However, throughout this period, children have faced inequitable access to education. Structural and historical racism has led to chronic underfunding and under-resourcing of schools that serve a large majority of children of color. Before the SARS-CoV-2 pandemic, 1 in 6 school-aged children in the United States were chronically absent, but certain subgroups of students—including males, students of color, students of lower socioeconomic status, and students with disabilities—exhibited higher rates. Data indicate an increase of at least 25% in national absenteeism rates during the SARS-CoV-2 pandemic.

These data further amplify the importance of the 2019 AAP school attendance policy statement’s charge to pediatricians to emphasize the long-term importance of regular school attendance with their patients, to support them with attaining this goal, and to help their communities to make school a welcoming, engaging space. The statement offers practical suggestions for individual interventions, especially related to acute and chronic medical conditions faced by school-aged children, as well as opportunities for partnership and advocacy with schools and government. However, such partnerships face obstacles. Privacy considerations, including those covered under the Family Educational Rights and Privacy Act (FERPA) and Health Insurance Portability and Accountability Act (HIPAA), must be considered when partnering to support a child or community. Secure data sharing can encounter technical and administrative hurdles. Furthermore, busy clinicians and school staff face capacity challenges that may limit their ability to explore new partnerships.

Nevertheless, there are bright spots to celebrate. Since Dr. Mitchell’s initial perspective on partnerships between health and education, pediatricians across the country have stepped up with clinical interventions and multi-tiered advocacy to support educational and health equity. For example, in Washington, DC, Children’s National Hospital and DC Public Schools co-lead a pilot called the Chronic Absenteeism Reduction Effort. Through that program, supported by United Health Foundation, families can provide a FERPA-compliant consent so that their child’s attendance data can be securely shared with their medical provider. Those data are then integrated into Washington, DC’s existing health information exchange, which captures other shared health data. The program team supports participating pediatric practices through quality improvement cycles as they engage with families who are experiencing or at risk for chronic child absenteeism. The pilot’s early outcomes are promising, with further evaluation planned.

As we proceed in the post-pandemic period and mark the 5-year anniversary of the AAP landmark 2019 policy statement regarding the pediatrician and school attendance, it is critical that pediatricians recognize the important role that they play in supporting their patients’ holistic growth and development, including their engagement and performance in school. Pediatricians must continue to lift up their trusted voices to call for equity and access to high-quality educational systems for all children.

References

  1. United States Census Bureau. A Half-Century of Learning: Historical Statistics on Educational Attainment in the United States, 1940 to 2000. https://www.census.gov/data/tables/time-series/demo/educational-attainment/educational-attainment-1940-2000.html
  2. United States Census Bureau. Educational Attainment in the United States: 2021. https://www.census.gov/data/tables/2021/demo/educational-attainment/cps-detailed-tables.html
  3. National Center for Education Statistics. 120 Years of American Education: A Statistical Portrait. https://nces.ed.gov/pubs93/93442.pdf

School-Based Health Centers and Pediatric Practice

Sonja O’Leary, MD, FAAP1, Anna Goddard, PhD, APRN, CPNP-PC, FAANP2

Affiliations: 1Director of General Pediatrics, Denver Health and Hospital, Associate Professor of Pediatrics, University of Colorado School of Medicine; 2Managing Director of Medical Services and Quality Improvement, Child and Family Agency of Southeastern Connecticut

Highlighted Article From Pediatrics

School-based health centers (SBHCs) are recognized as a prevailing model for collaborative, interdisciplinary health care in school settings for school-aged children and adolescents. They are especially recognized as the nations’ health care “safety net” for the uninsured or underinsured and to fill health equity gaps. The origins of school health services dates back as early as 1905 with physicians noting the need for school health action on the behalf of children.1

Where Are We Now

Over the years, studies have shown the effectiveness of SBHCs to improve both health and educational outcomes. Additionally, they reduce health disparities and are child-, adolescent-, and family-centric. SBHCs are recognized as potential medical homes2 and as an integral part of the medical village. Given the evidence that SBHCs decrease barriers for children and adolescents to access important services, including well child exams, immunizations, confidential sexual health services, and mental health services and treatment, the Community Preventative Services Task Force recommends SBHC implementation in all low-income communities to improve educational and health outcomes.3 The task force highlighted educational outcomes associated with SBHC implementation, including increased school performance, grade promotion, high school completion, and decreased chronic absenteeism. Further, associated decreases in asthma morbidity and emergency department and hospital admission rates all address critical obstacles to students’ education and long-term health.3

In addition to the AAP 2021 policy statement on SBHCs and pediatric practices, the National Association of School Nurses and School-Based Health Alliance have published a joint statement on the shared critical mission of the school nurse and SBHCs. The joint statement is an effort to work together to educate school districts on the importance of creating a culture of health in the school community.4

By 2020, there were roughly 64 million students 3-21 years of age enrolled in schools.5 The most recent SBHC census in 2016-2017 documented that SBHCs provided access to medical, mental, and oral health care services to 10,629 schools and over 6.3 million students.6 There were a total of 2,584 SBHCs throughout the United States, with most states represented. Currently SBHA, in partnership with Dr. Samira Soleimanpour and her team from the University of California, San Francisco, are conducting the next census, which will collect updated information on SBHC locations, staffing, services provided, populations served, telehealth services, and funding.

Pediatric primary care providers nationwide can attest to the devastating effects the SARS-CoV-2 pandemic had on the mental health and educational attainment of the nation’s children and adolescents.7 The CDC estimates that 1 in 5 children have a mental, emotional, or behavioral disorder. However, only about 20% receive care from a specialized mental health care provider. In a meta-analysis by Duong et al, the most common settings for mental health care were both school and outpatient settings.8 Schools can provide mental health care either by having mental health therapists employed by the school, co-locating community mental health services, or housing SBHCs. The unique nature of SBHCs allows the provision of mental health supports to students and families in need, including substance use counseling, suicide prevention, and mental health diagnosis and treatment, while also simultaneously collaborating with their medical counterpart to improve individual whole health.  

Where Are We Going

With mounting evidence of SBHC successes in decreasing health disparities and Community Preventative Services Task Force’s recognition of this model, expansion of SBHCs is ongoing. Interest from the National Institutes of Health (2021) and US Department of Health and Human Services (2021) include research dollars that further explore the effectiveness of SBHCs on health outcomes and the reduction of health disparities. The School-Based Health Centers Reauthorization Act of 2020 (H.R. 2075, 2020) called for dedicated funding from Congress for SBHC care. The 2022 Omnibus Appropriations for Fiscal Year 2022 was passed by Congress with $111 million specifically for school-based mental health services. Although federal funds have been earmarked for distribution to SBHCs and school-based mental health service care, the next few years will require continued collaborative commitments from local government to ensure that these federal dollars are spent wisely across the nation.

In this post-pandemic era, many more children could benefit from having an SBHC located in their school or school district. Locating clinical centers in buildings where children and adolescents spend the majority of their time and making mental health services more easily available are needed now more than ever.

References

  1. Mitchell H. School medical service in perspective. Pediatrics. 1965;35(6):1011-1014
  2. Albright K, et al. School-based health centers as medical homes: parents' and adolescents' perspectives. Acad Pediatr. 2016;16(4):381-386
  3. Community Preventive Services Task Force. Promoting health equity through education programs and policies: School-based health centers. Community Preventive Services Task Force; 2015
  4. National Association of School Nurses, School-Based Health Alliance (2021). School Nursing & School-Based Health Centers in the United States. Joint Statement. National Association of School Nurses, School-Based Health Alliance; 2021
  5. US Census Bureau. School Enrollment in the United States: October 2020—Detailed Tables. 2021
  6. Love HE, et al. Twenty years of school-based health care growth and expansion. Health Aff. 2019;38(5):755-764
  7. Mental Health America. Mental health and COVID-19.https://mhanational.org/mental-health-and-covid-19-two-years-after-pandemic
  8. Duong MT et al. Rates of mental health service utilization by children and adolescents in schools and other common service settings: a systematic review and meta-analysis. Adm Policy Ment Health. 2021;48(3):420-439

 

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