As the Change for Children programme progresses, Simon Collister looks at how more and more children with medical conditions are having their needs met in mainstream settings.

In recognition of this, updated guidance to assist schools and early years settings to manage children’s medical needs has recently been published by the DfES and the Department of Health (DH). Replacing existing guidance, Managing Medicines in Schools and Early Years Settings provides guidance for local authorities, schools, and parents to ensure they undertake good practice for common medical conditions.1 Forthcoming guidance from the Council for Disabled Children called Including Me2 will offer practical guidance on managing more complex health needs.

But where does government guidance on medical and health needs link up with its advice on special educational needs (SEN)? What is the overlap between the DfES’s Managing Medicines and its SEN Code of Practice? And what are the implications for SENCOs and other staff involved in supporting children with medical needs?

The code and medical needs The current code addresses medical needs at paragraphs 7.64 to 7.67. Paragraph 7.64 states: ‘A medical diagnosis or a disability does not necessarily imply SEN. It may not be necessary for a child or young person with any particular diagnosis or medical condition to have a statement, or to need any form of additional educational provision at any phase of education. It is the child’s educational needs rather than a medical diagnosis that must be considered.’

It would appear from this statement that SEN are foregrounded while medical conditions disappear into the background. This may be understandable given that the code is primarily concerned with SEN rather than medical diagnoses, but it risks implying that it is possible to identify children as having either medical needs or SEN. In reality children with medical conditions, such as asthma, allergies, diabetes or epilepsy, are more likely to experience learning difficulties as a direct, or even indirect, result of their condition. In order to provide the child with the appropriate support it is much more effective to recognise that the child’s additional needs are inter-related, whether they are health or education needs.

The code acknowledges this relationship between a child’s medical and education needs at paragraph 7.65. It informs us that: ‘Medical conditions may have a significant impact on a child’s experiences and the way they function at school. The impact may be direct in that the condition may affect cognitive or physical abilities, behaviour or emotional state. The impact may also be indirect, perhaps disrupting access to education through unwanted effects of treatments or through the psychological effects that serious or chronic illness or disability can have on a child and their family.’

When you read on from the code’s opening statement, it becomes clear that an over-simplistic divide between children who have medical conditions and those who have SEN rarely exists. Instead, a child may have a potentially complex matrix of learning, behavioural, emotional and physical difficulties that arise because of the underlying medical condition. Furthermore, the code highlights that these difficulties may affect the child directly or indirectly, depending on the nature or severity of the condition.

Practical solutions At present there is no statutory guidance or training to help education professionals address medical conditions, including epilepsy, and any related support needs. Therefore it is important for anyone working with children who have medical conditions to have access to resource material that gives information and guidance about the often complex relationship between medical needs and SEN.

A good starting point for basic guidance on the most common medical conditions is Managing Medicines. Where more detailed, condition specific, information is required, voluntary sector organisations are a valuable starting point. The four most common medical conditions encountered in UK schools all have national charities providing support and advice to education professionals. Diabetes UK, Asthma UK, Epilepsy Action and the Anaphylaxis Campaign, all provide material giving detailed guidance on managing and supporting children with each condition. All four charities also have school policies that outline children’s specific health needs and examine the implications of each condition on a child’s health and learning.

Epilepsy Action’s Epilepsy Policy for Schools is a stand-alone document divided into two main sections. The first section provides schools with key information about epilepsy, medicines and first-aid. The second section gives practical guidance on what procedures and adjustments need to be adopted when a current child is diagnosed with epilepsy or when a child with the condition enters school.
Information about school policies, training and other resource materials from the organisations mentioned above can be found through their respective websites listed below.

The way forward Looking at the range of issues which can impact on a child with epilepsy it becomes clear that a medical diagnosis, as determined by the code, is not as clear cut as it might at first seem. The code suggests a child’s medical diagnosis may or may not have an impact on their education. If there is an impact, it can be either direct and/or indirect and can be complicated by medicine side-effects as well as the emotional implications of having a chronic or long-term condition. Rather than viewing children with medical conditions as needing either separate health or education support, schools should aim to develop an integrated, inter-agency approach to ensure children with medical conditions receive the appropriate support across the spectrum of needs.

In the future, the government will move towards a model of integrated support. Such an approach is being introduced later this year in Scotland under the Education (Scotland) Act 2005. The act will replace statements of SEN with coordinated support plans (CSP). Under this system, children requiring additional support will have their needs assessed and provided with a CSP where necessary. The CSP will detail all the child’s needs regardless of whether those needs are educational, medical, or even social.

Until this system makes an appearance in England and Wales, schools and local authorities will have to continue developing their own integrated procedures for supporting children with medical conditions. Given that there is no statutory training on medical conditions and health and learning, schools and local authorities will continue to have limited access to information and resources and an uneven approach to supporting these children. One solution to this situation will be a complete multi-agency approach as advocated by the government’s Change for Children agenda involving health, education, social services and the voluntary sector. The Change for Children agenda is still at an early stage, but schools and local authorities can start preparing for the changes by seeking help and support from the voluntary sector.

As policy and practice moves more and more towards integrated support it seems untenable that we continue dividing children who require additional support into those who have health needs and those who have education needs.

Schools that adopt an integrated approach to supporting children with health and education needs, and local authorities who encourage schools to do so, are likely to benefit in two important ways. Firstly, children with medical conditions will receive appropriate levels of support that will lead to an improved quality of achievement. Secondly, schools and local authorities who commit to developing multi-agency working now will help set the groundwork for future Change for Children programmes.

Epilepsy: a case study The complex relationship between medical needs and SEN in the classroom is particularly well illustrated by epilepsy although the same principles can also be applied to other conditions such as diabetes and asthma. Epilepsy is a common condition affecting one in 242 school-age children who experience recurrent seizures unless these are controlled by medicine. There are about 40 different seizure types and only 52 % of children have their seizures controlled by medication.

Under current legislation, epilepsy is recognised as a medical condition and is covered by the Managing Medicines guidance. However, epilepsy is a medical condition that affects the brain. This means that in order to be fully supported, children with epilepsy require coordinated support that goes beyond basic first-aid training. The following examples demonstrate how epilepsy can impact directly and indirectly on a child’s health and education in the classroom. Because of epilepsy’s wide-ranging impact on learning and behaviour, it is vital for schools to fully understand the condition and undertake regular reviews of the child’s progress with parents or carers.

Direct impact

  • Learning: Although epilepsy is a medical condition, it can have a significant impact on a child’s cognition. Studies show that over two thirds (69%) of children with the condition in mainstream settings underachieve as a result of their epilepsy.3 Epileptic activity can cause short- and long-term memory problems and concentration difficulties. This impacts on reading and acquiring new skills. In particular, absence seizures can cause the child to lose consciousness for very short, but repeated periods. It is difficult to detect but can cause a child to miss class work. This affects their learning and can also be mistaken for defiant behaviour as the child fails to complete work. Absence seizures do not require first-aid, meaning that the only effect of this seizure type is education related.
  • Behaviour: Some types of epilepsy affect specific parts of the brain. Children who have these types of epilepsy may be more prone to motor difficulties and conditions such as dyspraxia. Similarly, some seizures cause children to display unusual or repetitive behaviour, such as walking around the classroom or attempting to undress. It is important that this is not mistaken as disruptive behaviour.
  • Access: Despite the implementation of the Disability Discrimination Act many children with epilepsy are still prevented from taking part in school visits because of fears over administering medicines or providing seizure first-aid. Schools can, and should, avoid unnecessary fears by having a comprehensive epilepsy policy.4

Indirect impact

  • Learning: Seizures that occur during sleep leave the child exhausted the following morning. This has implications for concentration and attention levels throughout the school day. Concentration levels can also be indirectly affected by medicines taken to control seizures. Some of these have a strong sedative effect and can leave the child with poor concentration and attention difficulties.
  • Behaviour: Behavioural and emotional difficulties are recognised as more prevalent in children with epilepsy than the general population. Research indicates that this could be as a result of: some anti-epileptic medicines; unpredictable seizures; low self-esteem and feelings of isolation. Bullying and stigma is also a significant problem for children with epilepsy.
  • Access: Some schools and LEAs do not understand epilepsy’s full impact on learning and behaviour. As a result children with the condition are at risk of being excluded for disruptive or defiant ‘behaviour’.

Simon Collister is education officer at Epilepsy Action.

Further information:

Asthma UK Adviceline: 08457 01 02 03 (Mon to Fri 9am to 5pm)

www.asthma.org.uk

Diabetes UK Careline: 0845 1202960 (Mon to Fri 9am to 5pm)

www.diabetes.org.uk

Epilepsy Action Freephone Helpline: 0808 8005050 (Mon to Thurs 9am to 4.30pm; Fri 9am to 4pm)

www.epilepsy.org.uk

The Anaphylaxis Campaign Helpline: 01252 542029

www.anaphylaxis.org.uk and www.allergyinschools.co.uk

References 1 For more information about Managing Medicines in Schools and Early Year Settings, see the article in SENCO Update, July 2005 2 Including Me: Managing Complex Health Needs in Schools and Early Years Settings. Forthcoming from the Council for Disabled Children. 3 Holdsworth, L and Whitmore, K (1974) ‘A Study of Children with Epilepsy Attending Ordinary Schools. 1: Their Seizure Patterns, Progress and Behaviour in School’. Developmental Medicine and Child Neurology 16. 746-758.

4 Free copies of a school policy are available from Epilepsy Action. Call tel: 0808 800 5050 or email scollister@epilepsy.org.uk quoting reference B111.

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