Resources for Clinicians

Engaging with parent(s)/guardian(s) before any consultation is always preferable, but when impossible (i.e., lack of response from parents, etc.), a child and adolescent psychiatrist can observe a child in a classroom and then consult to the teacher or school staff. Although the child and adolescent psychiatrist cannot interview or evaluate the child, or write a report indicating that a child “appears” to have any diagnosis, the child and adolescent psychiatrist may provide recommendations to the teacher, school counselor, administrators and/or other school staff (i.e., speech therapist, occupational therapist, etc.) about preferred strategies for working with the student’s behaviors or symptoms observed in that classroom.

The child and adolescent psychiatrist must always clarify what a school requires when it requests a consultation. Schools seek either (a) an individual evaluation for a student about a potential education disability and appropriate interventions, or (b) consultation on a wider school system need (e.g., managing bullying, responding to school threats, etc.).

(a) Individual evaluations: After parental/guardian consent is obtained, schools usually want the child and adolescent psychiatrist to:

• Review records;
• Interview staff, the student and parent/caregiver;
• Write a report summarizing observations and recommendations; and
• Possibly participate, in person or by phone, in a meeting with a child’s education team.

The child and adolescent psychiatrist can help by clarifying:

• Whether the student has a diagnosis (rule-out diagnoses are not helpful);
• Whether that diagnosis/condition interferes with academic or social-emotional education progress; and
• If the student would benefit from specialized instruction beyond counselling.

Families must understand that the student’s education team will make decisions about the student’s educational disability (e.g., social-emotional disability due to depression or anxiety), interventions and the appropriate school setting or placement. The child and adolescent psychiatrist can make recommendations, but the educational team will make ultimate decisions about the student’s needs, appropriate interventions, and educational setting.

(b) System consultations: The child and adolescent psychiatrist may often provide:

• Recommendations for resources such as school-wide programs, books/websites, etc., on relevant topics such as social/emotional learning, or creating a positive school environment; or
• Information at parent-teacher organization meetings or for professional development of school staff on issues such as identifying mental health concerns, barriers to early identification and treatment of mental health issues, or the mental health treatment referral process.

Schools want to better understand why a child has difficulty functioning in the classroom so reports should address the following:

• First: A diagnosis helps the school identify if a child has an educational disability. The inclusion of the specific symptoms impairing a child helps clarify targets for intervention.
• Second: Describing interventions for those specific symptoms can support teaching and learning. For example, the ADHD student who gets distracted quickly and loses items would benefit from sitting closer to staff or having staff check in to review information/directions, such as simply having pencils/paper available at school. Any intervention recommended should be both feasible in that student’s educational setting and benefit the other students in the classroom. For example, having a one-minute timer ring so that the teacher can reinforce a student is not feasible in most classroom settings. Moving a distracted child may benefit other students by reducing distractions. Having materials available may increase instructional time for all students by preventing time spent looking for pencil/paper.
• Third: Public schools are required by law to generally provide education in the least restrictive environment (LTE).  Providing schools with recommendations of appropriate interventions for a student alongside nondisabled students helps ensure schools comply with LTE requirements and may be more appropriate than recommending a child attend a specific alternative program or school.

FERPA

• At the federal level, FERPA and its implementing regulations protect most “education records” by classifying them as “confidential” and limiting their disclosure.¹
• FERPA applies to all educational agencies and institutions that receive funds under any program administered by the U.S. Department of Education. 
• An educational agency or institution that is subject to FERPA may not have a policy or practice of disclosing the education records of students, or personally identifying information derived from such records, without the written consent of a parent or eligible student, meaning a student who is eighteen years of age or older. 
• FERPA broadly defines the term “education records” to mean all records that are directly related to a student and are maintained by an educational agency or institution or by a party acting for an educational agency or institution.  Applying this definition, all mental health data that a public school district maintains on a special education student, including records of any mental health services provided under an individual education plan are “education records” for purposes of FERPA. 
• Similarly, all mental health data that a school nurse receives or maintains on a public elementary or secondary school student fall within the definition of “education records.”  This is true regardless of whether the school district employs the school nurse or contracts with an agency that provides nursing services to students, and regardless of whether the services occur on or off school property. 
• When contracting with a nursing agency, however, school districts would be well advised to include a provision in the contract confirming that the agency and its employees are required to comply with FERPA and any applicable provisions of state law.  The contract should also contain a provision confirming that no physician-patient or similar privilege will arise out of the nurse’s work with any student. 

HIPAA
           

• HIPAA is a federal law that was designed to protect the privacy and security of individually identifiable health information that is maintained by a “covered entity.” 
• This regulation requires “covered entities” to safeguard the privacy of health records and to limit the disclosure of such information without patient consent.  The law defines a “covered entity” to mean a health plan, a health care clearinghouse, and a “health care provider” that transmits health information in electronic form in connection with a covered transaction.²
• A “health care provider” is any person or organization that furnishes, bills, or is paid for health care in the normal course of business.²
• Many physicians do not seem to recognize that the HIPAA Privacy Rule permits covered health care providers to disclose private health information about a student to a school nurse for treatment purposes without parental consent.³
• For example, a student’s primary care physician may discuss the student’s medication and other health care needs with a school nurse who administers medication to the student or provides other care to the student at school.  Physicians who are aware of this rule may still construe the physician-patient privilege to preclude them from disclosing private health information about a student to a school nurse without parental consent. 

References:

1. http://www.ecfr.gov/cgi-bin/text-idx?rgn=div5&node=34:1.1.1.1.33
2. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html
3. U.S. Dept. of Health Hum. Services and U.S. Dept. of Ed., Joint Guidance on the Application of the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to Student Health Records, at 4 (Nov. 2008). 

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