Including Students with Chronic Health Conditions, Young Children (NAEYC), Ellie Goldberg, M.Ed., January 1994.
Children with chronic health conditions often have a tough time staying healthy at school and keeping up with their peers, but in Brookline, Massachusetts, a Transition-to-Kindergarten (TK) program shows how two students with special health needs can stay healthy and fit right in.
All it takes are a resourceful staff committed to building parent-teacher partnerships, the effective use of community resources, and a student-centered integrated whole-child curriculum.
When school started in September, 1989, TK teacher Judy Orlandi discovered that two of her 18 students had severe asthma and potentially life-threatening food allergies. Judy and her co-teacher, Harriet Kaplan, were nervous but undaunted. In keeping with the Brookline schools' early childhood education philosophy that every child's needs provide opportunities for teachers, children and parents to learn and grow together, they decided "the more you know, the less you worry."
They spent an afternoon consulting Lisa Gray, RN, at Pediatric Asthma and Allergy Associates. They read numerous articles as well as Children with Asthma, A Manual for Parents, by Tom Plaut, MD, a book they found "extremely helpful.” Brookline's school physician met with Brookline's entire early childhood education staff to discuss what they needed to do to make sure that student's needs were met and staff members' questions answered.
Using classroom activities to teach students about basic health issues is nothing new to Judy and Harriet. The year before, in response to student's interest in four pregnant moms, the class had turned the dramatic play area into a maternity/neonatal ward.
Now, Judy and her class decided to transform the play area into what they called the "TK Asthma/Allergy Hospital.” They began the project by brainstorming the supplies they would need. (Shots, stethoscope, specimen bottles, ambulance driver hats.) The children had many discussions about their own doctor visits, injuries and illnesses. They read books together for more ideas.
Combining classroom materials and parent donations, they assembled a variety of supplies including empty medicine containers, lab coats, surgical gloves, X-rays, and folders for medical records, a basketful of InspirEase (the collapsible holding chamber that Patricia and Josh used to help deliver aerosol medicine to their lungs) and disposable mouth pieces. Allen and Hanburys, Inc., a pharmaceutical company, provided coloring books and an array of posters and charts to decorate the room. The students made a variety of signs.
The TK "medical library" included So You Have Asthma, Too, and I'm a Meter Reader by Nancy Sander and Winning Over Asthma, by Eileen Dolan Savage, three books about asthma especially for young children.
The DeVilbiss Company, a nebulizer manufacturer, donated a Pulmo-Aide nebulizer, a small air compressor designed to make liquid medicine into a mist for inhaling into the lungs.
Before long, the play area was bustling with busy four and five-year old doctors in blue face masks answering the phone, listening to each other's hearts, and tending to an examining table full of baby patients getting shots, X-rays, band-aids, or breathing treatments. Each child had a personalized facemask. "So we don't catch germs from each other," explains five-year-old Jackson.
"Getting a chance to play with the medical equipment is very important for reducing children’s fears,” says Lisa. "Medical testing, needles, IV tubing, and surgical procedures are so scary for them."
She came to talk to the students about their lungs, the mechanics of breathing, and how everyone could take good care of themselves. Lisa also explained asthma, comparing the inflammation in the airways to the way scrapes or cuts in the skin become red, sore and swollen. Every child got to try his or her own InspirEase. As they breathed in, they listened for a wheeze-like whistle (a signal that the person is inhaling too fast).
"Everyone got to see what using the device feels like, to ask questions," Lisa emphasizes. "It is important to convey to kids that it is okay to ask questions about your body and your health, to be informed about your medical care."
Diane Limbo, RN, MS, a health educator at Boston Children's Hospital, visited to talk to the students about the people who work in the hospital, especially the emergency room. She arrived dressed in her regular clothes and introduced herself first as "a mommy," and then put on her hospital coat to become "TK's Nurse-in-Residence."
While she was there, she saw a lot of dramatic play illustrating the theme of getting hurt and being taken care of. "Children in this age group need this kind of play. It helps them cope with the things that worry them. Injuries, accidents, violence, and bad people are big worries for them."
"There was also a remarkable degree of mutual support among the students who brought their `babies' to the hospital," Diane noted. "Their waiting room talk involved a lot of consoling words and sympathy for each other."
This kind of dramatic play offers students many opportunities to express consideration for each other. It is an example of the varied ways that Judy and Harriet encourage curiosity and empathy in all areas of the TK program. Their goal is to enhance everyone's sense of belonging while working on cognitive skills and language development.
During one circle time, Judy asked all the children to make a statement or ask a question about asthma. "What is it like to have asthma?" she modeled a question for the group.
"Good and terrible," said Patricia.
"I throw up," said Josh.
"You cough," added someone.
"You can't eat stuff." contributed another.
Later, Judy pointed out that if Patricia or Josh need to stay indoors on cold days, a friend usually stays with them.
To help the class understand asthma, Judy asked the students to describe what it felt like when they have a cold and can't breathe well. The conversation was remarkably free of any social discomfort so typical of people who grew up when someone with a disability was rarely encountered as a friend.
In contrast to some schools that would expect Patricia to stay home during asthma flares or shunt her off to an isolated area to use her nebulizer, Judy enabled five-year-old Patricia to stay in class with her friends even on days when she needed extra medication.
"Judy and I would discuss the best time to fit in a breathing treatment," said Melita Malley, Patricia's mother. "The goal was to find a time that didn't interfere with Patricia's activities. Best of all, Patricia learned that asthma doesn't have to be a reason for her to miss out on anything."
Judy's efforts extended beyond the classroom. Her newsletter informed parents that "Patricia's breathing treatments at school have enabled the children to get a firsthand look at asthma and what having it sometimes involves. It does my heart good to see her sitting in the reading corner using her nebulizer with all her friends around listening to a story with her."
Because children are constantly bombarded with antidrug messages, TK students got needed reassurance about the benefits of medicine when they watch their classmates take it. "Medicine can keep you healthy and make you better when you are sick." explained 5-year-old Charlotte to a visitor during a tour of the play area.
Normalizing daily life for Josh and Patricia was good health education for everyone. When another child had to have his tonsils out, his mother reported that the class had prepared him to cope with his operation without unnecessary anxiety and apprehension.
Patricia's mother is extremely grateful for Judy's consistent efforts to ensure that students were safe in such a practical positive way. Like many other parents of severely allergic children, Melita finds that friends and family tend to underestimate the risks and frequently don't believe that small amounts of certain foods could be lethal. In TK, allergies were taken seriously and respected.
To reduce the risk of Patricia or Josh having a serious allergic reaction, Judy and Harriet explained to the class that they could not share food because it could make these two friends very sick. The program newsletter explained the new rules to parents: "We have two children with serious, potentially life-threatening food allergies, thus snack may not be a shared event. We remind everyone each day. Please reinforce this at home."
Anticipating upcoming birthdays, another newsletter added, "In the past we've often had birthday food treats from the birthday girl or boy to share with the class. Considering the fact that this year we have two children with severe food allergies we need to be a bit more thoughtful. If you want to send a food treat, you must let me know ahead of time so the parents of the allergic children can plan to send their own special snack on that day."
Judy also had alternatives available -- animal or ballerina stickers, for example. Instead of sending in food, families were encouraged to donate a book or puzzle to the program in honor of a child's birthday.
Even at home, students reflected the program's dedication to social inclusion and creative problem solving. One mother reported that when Patricia couldn't visit a classmate who has a cat, the resourceful friend was quick to suggest an alternative, "Can we go out with Patricia instead?"
To ensure that their approach to meeting students’ individual needs worked for everyone, two part-time social workers meet with teachers and parents on a regular basis. Barbara Murphy, early childhood/primary specialist, explains, "We build on our experiences with each child and each family. We keep working at it so we get better and better at doing it."
"We meet each child as an individual," says Judy, describing the strengths of Brookline’s curricular guidelines. "That is part of what we are doing with all the children--if the child happens to have asthma, food allergies, or whatever, it is part of the picture. You can't leave out a piece of the child. It's all important. Our program is designed to provide students and their parents with strategies and skills that empower them. We plan for the future, with his or her whole life in mind."
Barbara adds, "We not only deal with the needs of the individual child but with the impact on other children. When a child in one of the classes was placed in foster care, it had an impact on the other children that needed attention. In another group, a child with a significant developmental delay behaves very aggressively and scares the other children. In parent meetings we discuss how we are dealing with it and how teachers are supporting all the children. We help parents decide what to say to the children at home. It is never a question of one child's needs being met at the expense of anyone else."
Brookline's early childhood program's philosophy is based on the legacy of the Brookline Early Education Project, a ten-year comprehensive birth to kindergarten study funded by the Carnegie Corporation and The Robert Wood Johnson Foundation that showed the benefits of school-based early childhood education. Parents and teachers work as partners. They help each other because they have the same goals -- reducing risk and finding out what works best for each child. (Early Education in the Public Schools: Lessons from a Comprehensive Birth to Kindergarten Program, 1991. Hauser-Cram, Pierson, Walker and Tivnen, Jossey Bass Publishers, San Francisco.)
Indeed, TK staff members are selected especially for their dedication to the concept of parent-teacher partnerships. Throughout the year there are regular opportunities for parent-teacher communication including guided classroom observations, conferences, frequent newsletters, and a weekly Friday morning coffee time in the play area.
What would other teachers need to translate Judy's success to their classrooms? All the materials and resources are readily available to any classroom, Judy insists. Every community, large or small, has health professionals, social workers, and other specialists eager to collaborate with schools. One of the most important requirements is "taking the time to communicate."
Lisa agrees with parents that what Judy does in her classroom is "wonderful." Medical advances have enabled more children to lead active normal lives. Brookline's TK program shows how "wonderfully normal" it can get.
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