Other Health Impairments

Historical and Legal Perspective
Other Health Impairment (OHI) was included as an eligibility category in the Education for All Handicapped Children Act (1975), and has been maintained in the updated versions of the Individuals with Disabilities Education Act (IDEA, 1997, 2001 & 2004). Students who qualify are guaranteed special education and related services from ages 3-21 yrs. Infants and toddlers may access early intervention services from birth through age two via an individualized family service plan.
 * Americans with Disabilities Act (1990): This civil rights law was established to prohibit discrimination against people with disabilities in employment, public services and accommodations. It is indirectly related to ensuring the provision of a Free and Appropriate Public Education (FAPE), as guaranteed by IDEA.
 * Section 504 of the Rehabilitation Act (1973): Another civil rights law instituted to inhibit discrimination on the basis of disability. Section 504 guarantees a child a FAPE in the Least Restrictive Environment possible. Students may access related services through a "504," even if they do not qualify for special education under IDEA.

Federal Definition
Adapted Physical Education is defined as having limited strength, vitality or alertness, including heightened alertness to environmental stimuli, that results in limited alertness with respects to the educational environment, that: is due to chronic or acute health problems such as asthma, attention deficit disorder or attention hyperactivity disorder, diabetes, epilepsy, a heart condition, hemophilia, lead poisoning, leukemia, nephritis, rheumatic fever, and sickle cell anemia; and adversely affects a child's educational performance.

According to the federal definition this also includes Tourette's syndrome. This was included after some debate, when commenters had requested the inclusion of a number of disorders into the OHI category including: Tourette's syndrome, fetal alcohol syndrome, bipolar disorder, and others. Of these suggestions, only Tourette's syndrome was accepted into the OHI category. Other states have added inclusionary categories such as "acquired injuries to the brain caused by internal occurrences or degenerative conditions…" Over 200 specific health impairments have been identified (as of 2004), and most of them are rare.

Etiology
Since there are so many influencing factors for OHI qualification, there is no overall age of onset, nor is there any single cause for OHI (infection, genetic conditions, and environmental influences at all stages of life-before, during and after birth); however some can be categorized under the following:
 * Allergies (Hepatitis)
 * Heredity (Hemophilia)
 * Accidents (seizure disorders)
 * Multiple factors (Epilepsy)
 * Unknown

Diagnostic Criteria
Although it has been treated as such by some in the past, OHI is not a default category and must be determined via an evaluation by an Individualized Education Program (IEP) team. Eligible students must have a medical condition, but does not require a medical diagnosis (-although it is definitely helpful in understanding educational needs, OHI is primarily an educational disability; therefore, a medical diagnosis does not ensure OHI eligibility). If a school system requires a medical diagnosis in order to determine eligibility, it must be provided at no cost to the parent.

Prevalence
Data from U.S. Department of Education (2002) indicates that 5.1% of all school-aged students qualify for special education services under the category of Other Health Impairment. (Includes students aged 6-21 yrs.) This increase (351% from 1990-1991) is largely credited to the inclusion of individuals with ADD/ADHD. There remains much controversy over this inclusionary decision, citing these prevalence statistics as one of the arguments.

Specifically regarding prevalence of ADHD: It is often overlooked in females. Girls with ADHD do not get diagnosed until 12 yrs old on average, whereas boys typically are diagnosed by age 7. One of the reasons for this is that ADHD does not appear the same in girls as boys. Some ADHD symptoms to look out for in girls include: nonstop talking, troubles making/keeping friends, difficulty paying attention, disorganization/ exceptional messiness, and unfinished work. Most of these may result from the impulsivity that is a part of ADHD.

Terminology
Neither federal nor state legislation further defines all of the diagnostic criteria for OHI; however, the following definitions compiled by the state of Wisconsin may elucidate the requirements for eligibility for special education services under OHI.

1. Limited strength, vitality or alertness:
 * Strength: Power in body or muscles; when decreased, this negatively affects student's ability to perform regular school activities. Student may be physically unable to maintain performance optimally (e.g. holding a pencil and writing, standing or sitting all require physical capabilities).
 * Vitality: Physical and mental ability to maintain activity or energy level (endurance). Student might have the strength to hold a pencil and write, but only for short periods of time.
 * Alertness: Level of awareness, attentiveness to surroundings, etc. (Is student aware of what is happening in the environment around them?)

2. Chronic or acute health problem: It is not necessary to determine between the two for eligibility; however, this can be helpful in programming decisions. Some students may need intermittent services, while others will require more continuous care.
 * Chronic: long term, not curable, residual features place limits on executive functioning and result in a need for "special assistance or adaptations," and develops slowly and continues over time; May persist for the whole lifetime, and includes degenerative and deteriorating conditions
 * Acute: May be short term or persistent. Begins abruptly or rapidly, and symptoms are intense (severe).

3. Adversely affecting a child’s educational performance: The IEP team should discuss the specific ways in which the child's educational performance is affected.

Students receive education services at home, at school or in the hospital.

Measurement/Assessment

 * Any examiner assessing a student who may qualify for Other Health Impairments should be familiar with a wide variety of assessment tools, in order to accurately assess the child's cognitive and functional abilities.


 * Other areas that should be included in assessment are: gross motor, fine motor, and daily living skills; perception; recreation and leisure skills; augmentative communication; and sensory input. Competent diagnosticians recognize their personal limitations and seek help from therapists, educators, physicians, nurses, social workers, and others to gather appropriate data.


 * "Since the assessment of a student who has physical or health impairments is often time consuming and taxing to both the examiner and the child, the team of professionals should meet before data are gathered to consider: (a) the nature of the data base desired; (b) the potential use of the data; (c) specific measurement techniques or modifications of traditional measures; (d) who should present the items; (e) the method of data collection; (f) appropriate response modes and/or equipment; (g) position(s) for testing; (h) stamina and fatigue factors; (i) the order in which professionals will conduct the testing; (j) implications of medications for test performance and for the best time of day to test; (k) how data will be shared when evaluations are completed; and (l) the nature of nontraditional measures that should be incorporated in the assessment (e.g., evaluation of the child's milieu). Developing a comprehensive pre-assessment plan ensures that the information necessary for establishing programs and setting priorities for intervention will be available when needed."

Individualized Educational Plan (IEP) considerations
The IEP will specify how the impairment affects the student's performance in school. Some factors that should be included in the IEP to help determine the impact of the impairment are:
 * Pre-academic, academic, and classroom performance
 * Is the student functioning below grade/ability level?
 * Can the student accomplish academic/developmental tasks appropriate for his/her level?
 * Can the student follow directions/complete tasks?
 * Are there times of the day that the student is better/worse (includes behavioral, physical, emotional, attentional, etc.)? Can this be accommodated in the schedule?
 * Is the student easily distracted, requiring redirection; or exhibit memory problems of any sort?
 * Does the student experience/exhibit heightened/diminished alertness (over/under active)?
 * Does the student exhibit difficulty with time management or organization?


 * Attendance and loss of instructional time
 * Does the student miss school often as a result of a medical condition? Are services provided during these periods?
 * Does the student miss out on instructional time for health-care procedures (may be in-school)?
 * Are there side effects from medications (fatigue, attention, memory, etc.)?
 * Does student have trouble breathing that necessitates frequent breaks?


 * Behavior and social-emotional functioning
 * Does student exhibit behavior that impedes with learning (self or others)? Behaviors include bother externalizing (acting-out types) and internalizing (e.g. withdrawal).
 * How are the student's socializing skills (with peers, adults, parents)?
 * What do the student's behaviors look like during unstructured times (lunch, recess, home, etc.)?


 * Communication
 * Does student exhibit impaired communication (verbal/written)?
 * Consider some contributing situations: throat cancer, one arm amputated/injured, degenerative disease that makes breathing difficult, weak neck/head muscles as in cerebral palsy, etc.


 * Motor
 * How are the student's gross and fine motor skills (consider strength and balance problems, including muscle weakness)?
 * Does student have pain/swelling in joints or muscles during movement?
 * Can student move at a "normal" rate (i.e. keep up/pace with peers)? Difficulty moving within classroom, hallways, on stairs, in other areas of building?


 * Adaptive skills, vocational skills, and transition planning
 * What level are the student's adaptive skills at (living functionally in a community)?
 * Can student care for him/herself (bathroom, feeding, etc.)? Does s/he need instruction in this area?
 * Is there equipment that the student/other needs to maintain, clean, and operate relating to self-care (wheelchair, eyeglasses, etc.)?
 * How are the student's organizational skills? - Do they need bolstering here (help remembering medications, keeping track of health care providers, etc.)? –also consider whether student can read labels, and/or follow directions.
 * To what degree does the student understand his/her dietary and nutrition needs?
 * What careers might the student find success in/enjoy? What steps are needed to make this happen (schooling, placement, training, etc.)?
 * What resources may student access for financing school, medical expenses, housing, etc? Will they need to reapply for medical coverage?

Classroom Adaptations/Accommodations/Interventions
Teachers should consider any modifications they might want to make even before the student enters their classroom. Changes to the environment (table/desk settings) or to the schedule (break times) may be helpful to a student with an other health impairment. Changes should take into account factors such as fatigue, mobility, etc.

Teacher should be careful about overcompensating and being overprotective of students. They should avoid "exaggerated deference to the medical implications of a child's handicap." In the event that students must take care of some medical treatment during class time, it should be done unobtrusively, and the student should be allowed to go somewhere private with minimal attention, if they so desire. Social interactions and educational exposure should be maximized as much as possible (e.g. include food treats that fall within the student's dietary restrictions at class parties).

Choose curricula to meet individual student needs. Accommodations to the curriculum may include: adaptive response modes, adjustment to timing requirements or for limited hand use or mobility. Adaptive positioning equipment can help to position student so that they can interact more fully with their peers and gain valuable socialization skills.
 * Asthma: students with asthma miss over 14 million school days each year across the country. Maintaining a clean environment (no pets, clear ventilation, moderate temperature, low humidity, etc.) can help reduce danger and prevent asthma attacks from occurring.
 * Allergies: try to keep the child from trading lunches, seat child in well-ventilated area, be familiar with what child is allergic to, prohibit pets from regular classroom, and make adjustments for activities (woodwork, outdoors, etc.) that might be problematic.
 * Diabetes: try to keep child from trading lunches, make sure lunches and snacks are eaten at regular times (esp. on field trips), supervise child at all times, have sugar or juice available at all times, maintain a regular activity level.
 * Epilepsy: explain to student the nature of what they can expect (on a developmentally appropriate level), can assign a "buddy" to help a student return to class after a seizure, etc.
 * Tourette's syndrome: Can color code schedules, make sure to highlight important facts (instructions, due dates, operations symbols on math sheets, etc.), use visual as well as auditory cues, make sure there is enough space to maneuver between desks/rows, and ensure that searing arrangements don't make the child feel "on display."

Adaptive Equipment
As technology has advanced, more options have opened up for students with health impairments. Some students may simply require an inhaler and adaptations for classes such as physical education. Other students benefit from advances in medicine, such as slow release medications, and insulin pumps (for students with diabetes). Similarly, modifications in the environment can include use of specially designed desk, standing tables and similar equipment to allow the student to participate in a general education setting. However, there are many adaptive skills that can be bolstered by technology. Devices as simple as battery operated scissors, cup pourers attached to an arm, and biofeedback monitors can assist students with health impairments to participate more fully in a classroom with their peers. Additionally, tools are available to assist students who have difficulty with mobility, gross or fine-motor coordination, etc.

Care in school
It is important for all schools to develop a medical management plan for any students with health impairments so that students can be guaranteed appropriate care while at school. Many states have enacted legislation to require the training of some individuals to be able to medically assist students in emergency situations.

Individualized services
Special curricula may be beneficial for students in order to assist their development in specific areas. These may include (1) mobility skills, (2) self-esteem, (3) socialization skills, (4) adaptive behavior and self-care skills, (5) safety and emergency skills (includes education about the disability and health maintenance skills), (6) prevocational and vocational skills (transition services), and others.

Full-service schools
Most full-service schools have been designed for at-risk children. In this model of providing services, schools provide for educational requirements, as well as health care, mental health, and related services for both students and their families. In this way agencies and families work with the schools and can reduce the many difficulties that arise with transportation, health insurance, a lack of understanding from the school system, etc. The goal of this program is to provide the following services:
 * "Preventive services
 * Adult education
 * Immunizations
 * Family planning
 * Recreation
 * Afterschool care
 * Social services to access basic living resources
 * Economic services/job placement
 * Quality early childhood education
 * Mental/physical health screening
 * Consultation
 * Drug and alcohol prevention
 * Drop-out prevention
 * School meal programs
 * Child care


 * Early intervention services
 * Guidance and counseling
 * Tutoring
 * Public health care
 * Conflict resolution
 * Child abuse education
 * Juvenile alternative services
 * Latch-key services
 * Mental health counseling
 * Intensive treatments for chronic disabling conditions
 * Special education services
 * Related services
 * Emergency, crisis treatment
 * Case management"

Other Issues
Students may also experience some struggles in adapting to their environment with their impairment. Some issues they may face include isolation, boredom, depression, guilt, anger, fear, anxiety, low self-esteem or body-image, loss of control, medical noncompliance, and difficulty establishing one's identity, especially in social interaction with peers. While this list is not exhaustive, it provides some challenges to watch out for in order to provide appropriate care.

Current literature/research

 * Some current research is looking into cross-cultural effects of OHI, as well as other disabilities in order to recognize the differences in people more objectively and take into account the individual child's background more comprehensively.
 * Exposure to endotoxins (found in bioaerosols, waste collection, the textile industry, and more) may lead to development of an OHI. This is a concern especially in rural areas and in workplaces.