Diabetes Forecast May 2005

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Safe At School

Treating Diabetes in the Classroom
Diabetes doesn't take recess: It's a 24-hour, 7-day-a-week disease. Is your school properly equipped for treating your child's diabetes?
by Laurie Meyers

Your child has diabetes. You have learned how to monitor glucose levels, administer insulin, calculate carbs, and schedule snacks. You can spot the signs of blood glucose highs and lows, and you know what to do in an emergency. But who's looking out for your child at school?

Ideally, you rely on a school nurse. But many schools operate without full-time nurses because of budget constraints. Also, nurses generally don't go on field trips, attend athletic practices, or ride buses, so they aren't always there to provide routine or emergency care to every child with diabetes.

While some children with diabetes learn at an early age how to treat themselves, some still need daily help with administering insulin and other medications, testing for ketones, and monitoring glucose levels. All need help in emergencies.

The American Diabetes Association (ADA) wants to ensure that every child with diabetes is safe at school. It is working, therefore, to see that all school districts train other personnel, such as administrators, bus drivers, and teachers, to provide diabetes care when school nurses aren't present. Not everyone agrees that this is an appropriate solution. One teachers' union, for example, has argued that only medical personnel should be handling students' health needs.

But ADA points to Loudoun County, Va., as an example of a school district that has successfully launched such a training program for non-nurses.

"For children with diabetes, managing the disease is essential, not only for their health and safety, but for their intellectual and emotional development," says ADA President, Health Care & Education, Catherine J. Tibbetts, RN, MPH, CDE. "Diabetes care is a round-the-clock process, and we're committed to making sure that children receive the support they need during the school day. This means allowing students to self-manage their disease if they are able to do so, and having trained personnel available to provide help when needed."

One Success Story

Loudoun County is about an hour west of Washington, D.C.; it is one of the fastest-growing school districts in the country. The district currently has about 42,000 students, and an average of four or five new schools are being built each year. District officials estimate that Loudoun has between 100 and 150 students with diabetes.

Loudoun's diabetes training program didn't develop overnight, and it came about largely because of a group of concerned parents.

In the late 1990s, Loudoun's school board ruled that only medical professionals could administer glucagon shots to students. Glucagon is a hormone that is injected as emergency treatment for severe low blood glucose (hypoglycemia). Led by ADA volunteers Crystal Jackson and Sandi Pope, a group of parents, health care professionals, and ADA representatives appealed the ruling. They filed a complaint with the federal Office of Civil Rights of the Department of Education, and eventually took their case to the state legislature.

The result was a settlement agreement (specific to Loudoun County) and a statewide law, passed in 1999, that requires trained school employees, with parental consent, to administer glucagon and insulin. Loudoun subsequently created its diabetes training program.

Today, every Loudoun school that has a student with diabetes is required to have three employees who are trained to administer insulin and other diabetes medications and perform blood glucose checks, among other diabetes-related duties. School personnel volunteer to take on these duties, and any employee may sign up.

In addition to those volunteers, all teachers who interact with students with diabetes are trained to identify signs of low and high blood glucose. Bus drivers, athletic trainers, and coaches are all equipped with and trained to administer glucagon.

The training is provided by district nurses who were themselves trained by a local certified diabetes educator, Sherry deMilt, CDE, RN. Employees who are being trained to administer insulin or glucagon must demonstrate proficiency to the supervising nurse, and they are urged to practice monthly. Each classroom has a chart that lists the names and locations of the trained employees. Walkie-talkies are available for emergencies, and each student with diabetes has a kit with supplies and care instructions.

Loudoun found ways to offset the costs of training with help from the community. Plastic "practice arms" were donated by the local rescue squad. Ongoing training is provided by salaried district nurses. The biggest expense is syringes, which Loudoun orders in bulk through the state health department.

A Helping Hand For more information on ADA's "Safe at School" campaign, as well as state and federal laws that affect you, call 1-800-DIABETES (1-800-342-2383). Tell the call center representative that you're interested in speaking with ADA's legal advocate and receiving a free school discrimination packet. The advocate can talk to you about any specific problems you may be having with your child's school. ADA's school discrimination packet contains information on protecting the rights of children in schools and day care centers. The packet also includes information for educators, and samples that can help you design what's called a "504 Plan" and a "Diabetes Management Medical Plan." These plans outline the specific treatment your child needs and who should be responsible for providing it.

How's It Going?

Loudoun's program is working well, according to Anne Lewis, the district's education and program manager, and Cathy Sturgeon, its director of health services. The training enabled volunteers to spot symptoms before serious health problems developed, they say. In one case involving a high school student, "the student was not acting right, was belligerent and confused, unable to follow directions," Sturgeon says. "Because the principal had training, he was able to recognize this as a blood sugar issue."

Ron and Wendy Boxall, whose 7-year-old son, Bailey, has type 1 diabetes, are grateful for the training Loudoun's staff has received. They recently moved to Loudoun County from Florida, where Bailey attended a school without a diabetes program.

The Boxalls are pleased with the care their son is getting in Loudoun County. "People are trained, Bailey is well cared for, and most important, he is flourishing academically. We could not be happier," says Ron Boxall. "As a Navy family, this is our third move since Bailey was diagnosed. We don't want to leave. We love that Bailey's diabetes needs are not really a huge issue, and we are finally comfortable when he is not in our care."

Legal Protection

So, if this large and rapidly growing school system can implement such a plan, could yours? On your side are several federal laws, including the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973, which have been used effectively to fight discrimination against students with diabetes to make sure they are medically safe and have access to all educational opportunities. In addition to these laws, the federal Individuals with Disabilities in Education Act provides federal protection for some students with diabetes. Most states have their own laws providing additional protections.

However, some states also have laws that restrict certain procedures, such as injections by nonmedical personnel. This can make it difficult for school districts to know how to handle children whose special needs include the administration of medications through needles.

Is It Safe?

Not everyone agrees that programs such as Loudoun County's are appropriate. Janet Bass is a health spokesperson for the American Federation of Teachers (AFT), an AFL-CIO affiliated union that represents 1.3 million educators, health workers, and government employees. Many school nurses belong to AFT. Says Bass: "All children with special health needs should have the services of a full-time school nurse. Anything less is dangerous for the student, the employee, and the school district. The best solution to the health needs of schoolchildren is to have a nurse in every school."

The National Education Association (NEA), which represents 2.7 million educators, has not developed a position on this issue.

But many medical professionals trained in diabetes have said that programs such as the one in Loudoun are not only safe, but necessary. In addition, "children cannot perform as well and learn as well if their [blood glucose levels] are not at the proper level according to their doctor's plan," says Lori Laffel, PhD, MD, head of the pediatric and adolescent department at the Joslin Diabetes Center.

One of the concerns raised by AFT is that giving glucagon is a dangerous practice. Laffel contends that the greater danger is in not being able to give it, and adds "you cannot overdose on glucagon. If someone gets glucagon but didn't really need it, it wouldn't harm them."

In addition, the National Diabetes Education Program (a joint program of the National Institutes of Health, the Centers for Disease Control and Prevention, and 200 partner organizations) has issued a school guide, Helping The Student With Diabetes Succeed: A Guide For School Personnel, which emphasizes the importance of having trained school personnel available at all times. Go to www.ndep.nih.gov/resources/school.htm for a free copy of the guide or call 1-800-438-5383.

What Can I Do?

ADA has developed a campaign called "Safe at School" that is designed to help families like yours learn more about diabetes care in school. A team of experts is available to help you understand the federal and state laws that affect you and how you can advocate on behalf of your child. (see sidebar, "A Helping Hand," above)

Your first step as a parent of a child with diabetes should be to talk to your child's principal, school nurse, and teachers. Explain your child's needs. "A lot of people think they know about diabetes, but they really don't. Be prepared to give them a little training," says Loudoun's Anne Lewis.

Enlist the support of your physician, your local diabetes educator, and other parents. You may be able to show your school that with the correct training and a physician-directed plan, nonmedical personnel can safely participate in diabetes care.

Be patient but persistent. You are your child's most important advocate.

Laurie Meyers is an associate editor of Diabetes Forecast.