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When summertime turns to school time: Common school-related health concerns

Summer's end brings school buses, homework and after-school sports. It is also the season when many families start talking to their children's clinicians about concerns they may have regarding school and their child's health.

We spoke to Kathleen Conroy, MD, MS, of Boston Children's Primary Care at Longwood, about the top school-related concerns she hears about from families and her practice's approach to some of them.

Lifestyle management: good routines, good sleeping, good eating

Back to school is a time of transition and a time when summer habits have to give way to school routines. "For small children, routines are particularly important for their sense of well-being," Conroy notes.

So is sleep, an issue that, with the rise of the connected teenager, is becoming an ever-greater one for adolescents. "There isn’t enough discussion about good sleep hygiene," Conroy says. "We need to stress that adolescents need a solid eight to nine hours of sleep every night. Otherwise, the sleep deprivation can contribute significantly to headache, stress and a general sense of not feeling well, which can in turn affect school performance and behavior."

A major challenge in establishing good sleep hygiene, Conroy says, is eliminating screens from a child's bedroom, especially as the days get shorter and homework loads increase. "It's important to talk to families and brainstorm ways of getting away from screens around bedtime," she says.

"And if a child has insomnia," she adds, "it's important that she should get up at the same time every morning. Inducing a little sleep deprivation can help them get back on track and establish a strong bedtime routine."

Nutritional routines can also play an important role in good school performance. "Back to school is a good opportunity to raise with families the importance of breakfast and also the benefits of eating dinners together as a family," she says.

Headaches

Conroy notes that she sees a significant increase in headache complaints during the school year, but that for most children, it's largely an issue of lifestyle and habits. She specifically cites caffeine, loss of sleep, dehydration and stress as primary culprits in headaches during the school year.

"If a child has a history of headaches, we as PCPs should work with the family to find ways to prevent headache cycles through lifestyle change," she says. "Sleep in particular can play an important role."

Preparing for and managing chronic conditions

"School often brings out concerns about proper management of chronic conditions such as asthma, allergies and diabetes," Conroy says. "We think the best approach is one focused on management and preparation." It's important, she notes, to work with the families and school administrators of such children to ensure that:

  • there is a management plan in place
  • the appropriate medications are available at school should they be necessary (e.g.,  EpiPens for children with allergies, albuterol and an appropriate spacer for those with asthma; insulin and glucagon for those with type 1 diabetes)
  • the proper permission forms and instructions have been filed with the school so the school nurse or other staff can provide medication if necessary

Mental and emotional well-being

The academic and social aspects of school can be a significant source of stress, particularly for adolescents. In some cases, these stresses can manifest themselves as changes in mental or emotional health, including depression and anxiety. Here the PCP can play a significant role.

"PCPs should be comfortable screening children and adolescents for mental health problems, collaborating with psychologists and psychiatrists in the care of children, even starting psychiatric treatment," Conroy says. "Given that there are insufficient mental health specialists to meet the growing mental health demands in children, we need to take a medical home approach to managing the care of children with mental or emotional difficulties."

ADHD and other learning challenges

Conroy explains that attention deficit hyperactivity disorder (ADHD) and other learning problems also take more prominent roles in her practice during the school year. "It's important that physicians, families, teachers and administrators are all on the same page when it comes to planning for the well-being and education of a child with a learning disability," she notes.

Conroy says she and her colleagues see many families approach them with learning concerns around the time children turn 5.

"Often, they come to us in the first month of kindergarten worried that their child doesn't seem to be learning at the same pace as his peers," she explains, adding that kindergarten teachers are often the first to notice that a child may have learning challenges.

Conroy lists a few of the parental concerns about ADHD and other learning challenges where she thinks PCPs can play an important role as facilitator and advocate for families:

  • When and how should we approach our child's teachers and school administrators if she has been diagnosed with a learning disability?
  • How do we ask for and help create an individualized education plan (IEP)?
  • When should we ask teachers to fill out Vanderbilt surveys for my child?
  • If my child needs medication, how do we make sure the school has the necessary doses and the clearance to provide them?
  • Are there technological or electronic tools we should consider that can help coordinate our child's care?

PCPs can also play a very important role in counseling families through the process of developing an IEP. "We can help families understand their rights when it comes to advocating for their child and obtaining the services they need," Conroy says. "In that regard, it's important to have relationships with the officials in your patients' school districts who can help facilitate the process."

On the field

Moving from the classroom to the field, sports-related preparations and care are also common concerns, especially as related to concussion. "If a child will be playing sports during the year—not just fall sports—where there is a risk of concussion, suggest to parents that they talk to their child's coach about pre-season neurocognitive testing," Conroy says, pointing out high-risk sports such as football, lacrosse, soccer, ice hockey and field hockey. "Should a child suffer a concussion, this will provide a baseline assessment that will help guide her recovery."

She adds that when filling out team-related health forms, PCPs should make an effort to counsel children and parents about the importance of wearing proper protective equipment so as to avoid concussions or other sports injuries, and stress again the need for a good night's sleep.

Helping children with a history of concussion return to school and return to play should be a team effort. "If a child has had a concussion or other head injury, it's important to get her, her family and her coaches invested in the idea of keeping her off the field until her symptoms have resolved completely and she's had a sufficient period of rest," she says. "These conversations need to happen before the season starts."

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