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Students With Chronic Diseases

Posted on: Sunday, 3 August 2008, 03:00 CDT

By Taras, Howard Brennan, Jesse J

ABSTRACT BACKGROUND: To educate children with chronic diseases in the least restrictive environment, schools must prevent, recognize, and react appropriately to symptom exacerbations. Schools are often pushed to their limits of knowledge, resources, and comfort level. This study determined the health conditions of students for whom districts seek school physician consultation and the nature of school physician consultants' involvement.

METHODS: A retrospective record review was performed on 250 of the most recent records of school-elicited referrals from an academic center that provides physician consultation to school districts. Referrals were sent from 8 school districts in southern California (July 1996 to October 2006). Data collected were nature of student's special health need, the school physician consultant's intervention required to satisfy schools' needs, student grade level, enrollment in special education, and health-related excessive absenteeism.

RESULTS: No single chronic condition, symptom, or special health care need predominated. Six types of school physician consultant activities were used to overcome hurdles schools faced when accommodating students with special health care needs. The 3 most common were direct communication with students' own physicians (70% of students), recommending an appropriate level of school health services when this was a matter of controversy (42%), and formulating portions of students' individualized school health plans (38%).

CONCLUSIONS: A portion of students with special health care needs benefited from district referral to a school physician consultant. Whether some of these referrals can be avoided if school personnel and students' own physicians are supported and trained to communicate more effectively with one another needs to be explored.

Keywords: children with disabilities; chronic diseases; health communication; health policy; school health services; school physicians.

There is a high prevalence of children with chronic conditions in our nation's schools. The National Survey of Children with Special Health Care Needs demonstrated that 12.8% of 0- to 17-year-olds meet the federal Maternal and Child Health Bureau definition for having a special health care need ("those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition who also require health and related services of a type or amount beyond that required by children generally").1 There are peak childhood prevalence rates in many Western nations for insulin- dependent diabetes,2 severe food and insect sting allergies,3 and asthma, particularly among certain races.4 Autism and emotional and behavioral disorders have become more prevalent.5 As many as 26% of children in early childhood special education programs received medications, and 16% reportedly used medical equipment such as nebulizer machines and breathing monitors.6 In all grades, there are now larger than ever student population with cerebral palsy, respiratory compromise, seizure disorders, and reliance on daily medical technologies or therapies in school.7-9

Attendance is a problem for many of these students. Among children with functional limitations, 27.9% reported missing more than 11 days of school in the previous year because of illness or injury, and the biggest concern among their surveyed educators was their increased absence rate.10-12 In a study of parent satisfaction with students' individualized education programs (IEPs), it was found that the least satisfying IEP meetings for parents were those held for children with health impairments and that these were largely due to differences in parents' and school staff members' perceived needs of the child.13

Medical innovations, societal attitudes, educational trends, and federal laws call for schools to integrate these students into regular programs, school sites, and classrooms. Two federal laws, Individuals with Disabilities Education Act and section 504 (of the Rehabilitation Act), are most conspicuously responsible for this integration.14-17 Parents and child advocates from various professions demand that schools adhere to the letter and spirit of these laws. Increased costs for special education are primarily due to increased health care costs incurred by schools.18 Accommodating students with services and resources they need in the least restrictive school environment requires an understanding of each student's condition and level of fragility. It also requires health professionals who are adequately familiar with the school environment, transportation modes to school, and the variety of strategies schools can use to accommodate health-related needs. School administrators rely heavily on school nurses and students' prescribing physicians to find the right balance to safely accommodate these students.14,17 If students' physicians do not fully understand the limits and abilities of schools, they may not provide these schools with adequate or appropriate information. These physicians may unwittingly over- or underprescribe schoolbased nursing and other health-related services. Providing excessive resources for these students places an unnecessary drain on educational funds and dishonors the spirit of the "least restrictive environment." Providing too few resources for these students can create an unsafe environment and be unfair and unlawful in many cases. This sometimes results in overburdening a parent with the care of a child during the school day. Schools are often pushed to their limits of knowledge, resources, and comfort level to accommodate the needs of all students.

Although many school districts do not use school physician consultants, school physician consultants are more likely to be prevalent in many urban schools and in certain states, such as Maine and Massachusetts.19'20 The role of school physician consultants has been defined in several ways, all of which include a role in bridging communication between the school team and the community health services.20-22 Physicians' specific role for students with chronic illnesses has been defined (eg, as an advocate and to define medical services) .23 The role of a school physician consultant to school districts and a resource to school nurses, specifically to help schools manage students with a chronic disease, is supported by the Centers for Disease Control and Prevention, Kaiser Permanente, and the American Lung Association.24,25 They recommend that each district ensures access to a school physician consultant for each school. The sort of situations that induce a school district to use school physician consultants may be an indication of those circumstances where schools are least likely to safely accommodate students with chronic diseases using their own internal resources. The purpose of the current study was to determine the type of medical diagnoses and the school circumstances that prompt schools to seek medical consultation and the response of the district medical consultant.

METHODS

Design, Setting, and Participants. A retrospective evaluation of records was performed on 250 of the most recent cases referred to the Division of Community Pediatrics at the University of California, a unit that specializes in medical consultation to school districts. These cases spanned a period between July 1996 and October 2006. If any student received 2 or more separate referrals over the course of the 10-year period of data collection, only data associated with the first referral were included here so that the 250 records represent 250 individual children. Reviewed records consisted of the following written documentation in the school physician consultant's records: letters, e-mails, and typed notes.

Each referral came from staff at schools or central administration from any 1 of 8 school districts in southern California. These districts shared the characteristic of having several to many school nurses (registered nurses with a minimum of a bachelor's degree and certification in school nursing). Altogether, these school districts educate approximately 262,000 students per year and cover ages 6 months to 21 years. District sizes range from 14,600 to 140,700 students.

Measures. Records were reviewed for grade level of child (enrollment in any prekindergarten, elementary, middle and high school, as well as students aged 18-22 years not in a traditional high school), enrollment in special education (when it was apparent from the notes that a student has an active IEP or individualized family service plan or that the student was being assessed for such a plan, the student was classified as special education), if a stated purpose of the referral to a school physician consultant was excessive absenteeism for a health-related condition, the nature of school physician consultant intervention offered as a result of the referral, and the child's medical diagnostic category. Medical diagnostic categories were broken down into conditions and were based partially on body systems (gastrointestinal, neurological, hematological, dermatologie, etc); however, conditions were also categorized further into special needs that reflected what school personnel were interested in (eg, how to respond to recurrent pain in school; gastrostomy tube feedings, conditions that are degenerative-because that feature affects development of educational goals). No student was included in this study more than once. If any student received 2 or more separate referrals over the course of the 10-year period of data collection, only data associated with the first referral were included here so that the 250 records represent 250 individual children. Data Analysis. Chi-square tests were used to compare the frequency of school physician consultation activities with student grade level and special education status. Chi-square tests were also used to compare student special education status with grade level and excessive absenteeism (as defined by referring school or district) as the reason for referral. Only 3 categories of grade level were used in analysis (pre-K, elementary, and middle to high school); the 18- to 22-year-old category was excluded due to insufficient sample size. All statistical comparisons were conducted using SPSS 14.0 (SPSS Inc, Chicago, 111).

RESULTS

Characteristics of Students. Of the 250 students, 157 (63%) were known to be in special education or being considered for a special education program. In addition, the highest proportion of student referrals were made for students in elementary school (48%), followed by middle to high school (26%), pre-K (12%), and 18- to 22- year-olds (4%). Grade status could not be determined for 24 students (10%). No statistically significant difference was found between special education and non-special education students across grade level, kappa^sup 2^(2, 215) =4.35, p = .11.

Chronic Condition, Symptom, ana Special Health Care Needs. All students in the sample had at least 1 chronic condition, symptom, or special health care need (Table 1). No category of condition or special need predominated. Greater than two fifths of the students (41.6%) were identified as having more than 1 chronic condition, symptom, or special health care need, as categorized here. The most frequent conditions for students were identified as seizures (15.2%), other neurological disorders (eg, cerebral palsy) (14.8%), and asthma (12.8%), while the least frequent conditions were identified as severe allergies (1.6%) and hematological disorders (1.2%).

In 36 (14.4%) of referred cases, excessive absenteeism was at least 1 reason for the referral by the school district and was more frequently the case for nonspecial education students (21.5%) than for special education students (10.2%), ?2(1, 250) = 6.07, p = .01. This includes situations where the student's absences were felt by school personnel to be secondary to the chronic condition or district personnel were skeptical of parents' attribution of their child's chronic condition as cause of poor attendance.

School Physician Consultation Activities. Review of the 250 records revealed that most school physician consultant interventions provided as part of the service to the referring school district fell into 1 or more of the following 7 categories:

1. Direct communication between the school physician consultant and the child's own physician. Letters and telephone calls were documented for 176 or 70.4% of referred cases. One illustrative example was when the school physician consultant reached a student's doctor on the telephone to clarify her rationale behind a signed form for medically justified homebased education or for physical education exemption. Another example was when the school physician consultant recorded a student's behavior, as observed at school, in a letter addressed to 1 of the student's doctors in order to elicit the doctor's opinion on whether the likeliest etiology for the behavior was the medication, an underlying neurological or psychiatric issue, or a reaction to circumstances experienced at school.

2. Recommending an appropriate level of school health services when there is discrepancy of opinion. Decisions were made on what constitutes safe placement and level of health care services for 104 or 41.6% of referred student cases. One illustrative example was when the school physician consultant assessed the environment of both a public school and a nonpublic school for suitability for a child with an immune deficiency to help the district determine an appropriate placement from a health perspective. Another example was to help the district determine, given a student's medical history and diagnoses, whether an air-conditioned classroom during warm months is truly a health requirement for a certain student with underlying health conditions.

3. Medical input into developing an individualized school health plan (ISHP). School physician consultant input into the development of a detailed ISHP occurred with 95 (38.0%) referred cases. An illustrative example was when the school district consultant helped the school nurse determine how a mentally retarded student with a seizure disorder, insulindependent diabetes, and hypoxic episodes during exertion should be cared for during the school day and during transportation to school by brainstorming on several possible ways to provide adequate levels of observation and response to his needs while maximizing his educational opportunities.

4. Educate school staff members on a particular health condition. School staff were educated on a specific medical condition for 53 (21.2%) referred student cases. This may have been informal or formal, large groups, small groups, or individual education. Sometimes, educational goals were modified as a result of having provided this information, so that educational goals more realistically reflected what was possible, given student's health condition. An illustrative example was education provided to school staff for a student in special education who had Leigh's disease accompanied by dystonic cerebral palsy, fructose intolerance, and a marked scoliosis (where a corrective brace was discontinued because of interference with coughing). The school district consultant provided information on the etiology and prognosis of the disease and its complications, which was helpful to school educators and therapists for purposes of educational planning.

5. Establishment of a system for ongoing communication between school personnel and the child's physician. The establishment of a recommended protocol to inform the students' physician of classroom progress and problems was developed for 53 (21.2%) referred student cases. These were in the form of a report, a protocol, or a verbally recommended change in general district or school policy. Often, this was necessary when parents were not in a position to consistently or accurately be the only communication link between the managing physician(s) and the child with the chronic condition. An illustrative example was associated with a second-grade student with diabetes. The school physician consultant devised a plan acceptable to all whereby the school nurse would begin to fax the student's recorded blood glucose levels to his endocrinologist's office every week. The endocrinologist's office was otherwise unaware of the child's marked and consistent hyperglycemic values. Another example was when the school physician consultant developed systems for schools to report school learning problems and school behaviors that resulted from new medication regimens prescribed for students with diagnoses like seizure disorders and autism with aggression.

6. Assist the family with navigating the health system (eg, finding a suitable specialist, exploring resources for a child without health insurance). An illustrative example was when the school physician consultant assisted a family with getting a more timely appointment with a doctor because the parent had failed to convincingly express the urgency. Some level of assistance occurred for 26 (10.4%) referred cases. Another example was associated with a child whose several health problems had affected her academic achievement and attendance and she was without a medical home or health insurance. The school physician consultant assisted by helping the family and student's circumstances to be properly screened. This family was found to be medically and financially qualified for subsidized medical examinations and ultimately some limited health benefits.

7. Other. Interventions that did not fall into any of the above categories occurred in 6 (2.4% ) referred cases. One example was when the school physician consultant met directly with a parent at the child's school site to reiterate and reinforce what school staff and their own health care providers had previously tried to explain about certain restrictions that were necessary. Another example was when the school physician consultant investigated the school and classroom environment to help determine what was causing a student's respiratory problems solely in those settings. This involved performing a small epidemiological survey of other student's symptoms and rates of absences and interpreting laboratory results of particulate environmental measurements to determine ambient levels of likely offending allergens and irritants.

Of the 250 case records reviewed, 46 (18%) required 1 of the above school physician consultation activities, 145 (58%) required 2, and 58 (23%) required 3 or more. Recommending an appropriate level of school health services when there is discrepancy of opinion occurred more frequently for referred special education students (52.9%) than for referred non-special education students (22.6%), chi^sup 2^(1, 250) = 22.05, p < .001. Establishment of a system for ongoing communication between school personnel and the child's physician occurred more frequently for nonspecial education students (33.3%) than for special education students (14.0%), ?2(1, 250) - 13.05, p < .001. No other statistically significant differences were found between school physician consultation activities and special education status (Table 2). Medical input into developing an ISHP at school occurred more frequently among pre-K students (48.4%) and middle to high school students referred to the school physician consultant (47.7%) than for elementary students (31.1%), chi^sup 2^(2, 215) = 6.35, p = .042. In addition, assisting the family with navigating the health system occurred more frequently for referred elementary students (17.6%) than for referred pre-K students (3.2%) and middle to high school students (0.0%), chi^sup 2^(2, 215) = 16.19, p < .001. No other statistically significant differences were found between school physician consultation activities and student grade level (Table 3).

DISCUSSION

Because this was a retrospective study, certain data were not available and some analyses could not be performed. For example, as not all school districts were contracted to use school physician consultation services each year, the number of school physician consultations per 100,000 student population per year could not be determined. Similarly, nurse-to-student ratios varied over time at any 1 district and between districts. These data are not available, and therefore, it is not possible to examine the relationship between nurse-to-student ratios and number of referrals to a school physician consultant. Although several doctors have provided school physician consultation to districts from this academic unit, only 1 doctor provided such consultation services during this data collection period, and it is possible that the types of student case referrals overreflect the interests and expertise of this school physician consultant. The members of the school district staff who referred students' situations to the school physician consultant included school nurses, school administrators, school psychologists, occupational therapists, physical therapists, and special education teachers. As the source of the referral was inconsistently recorded, it is unavailable.

These data do not represent the proportion of children attending school with chronic diseases. For example, although asthma is arguably now the most common chronic condition requiring medication in school, this represented only 32 of the 250 referred cases. Another example is that although autism spectrum and attention deficit disorders are relatively common, they were relatively uncommon in this sample, presumably because the input of a physician other than the student's own physician is not commonly elicited for many of these children. What is significant, unique, and useful about these data are that they represent the subset of schoolchildren with a chronic condition or special health care need where school districts' internal resources benefit from school physician consultation as they try to safely integrate students into educational settings. Arguably, these data contain indicators of health topics for which current and future physicians must be adequately trained.

Although using school physician consultation may be viewed as a legitimate way to deal effectively with difficult school health circumstances, it may also be viewed as a gap in our educational and/ or health systems. Referrals appear to occur during circumstances where educational placement, expected academic achievement, and optimal health management plans are developed too slowly, with inadequate clarity or with avoidable acrimony or are rife with considerable complexity. The results of this study (ie, school physician consultant's role in setting up of communication protocols and recommendation of appropriate health services) suggest that there may be a lesser need for a school physician consultant if pediatrie caregivers and school personnel had support systems that enable them to communicate more efficiently and consistently about children they share responsibility for and if more physicians understood the school environment. The higher frequency for differences in opinion on what constitutes an appropriate level of schoolprovided health services among special education students, as compared to those not in special education programs, may be a reflection of an elevated degree of savvy among parents who have had to advocate for both special educational and special health needs within a highly regulated system (special education programs). The higher frequency of school physician consultant assistance in developing an ISHP for students in preschool, middle school, and high school as compared to students in elementary school may be related to demands these children face as they enter a new environment. As children spend more time in elementary schools (6 years) than in special prekindergarten programs (1-3 years), middle school (3 years), or high school (4 years), they require changes in their ISHP less frequently during those relatively stable years.

These results suggest that many problems solved by a school physician consultant are reactions to contentious or complex problems, problems that may be more readily dealt with if policies and systems were in place to support a proactive approach, an approach that school nurses would likely appreciate and champion if school administrations were to recognize the need. One example is that from at least 1 study of students with cerebral palsy, we know that parents' relationship with health and educational systems is often a function of their early history with large institutionalized health and social systems, characteristic coping strategies, a student's level of severity, a student's need for behavioral and therapeutic parental attention, and the extent to which a parent feels supported within the immediate family.26 Parents of children with chronic illness feel that their children are more vulnerable than do parents of other students. This perceived vulnerability is a predictor of poor school adjustment.27 Parents themselves are more likely to have psychological and physical health problems and are likely to perceive the quality of their life as dependent on their ability to advocate for their child.28-30 If school administrators and educational professionals and children's own health care providers were trained to recognize these family needs and to work collaboratively with other professionals and with parents when their children were ready for school entry, parents may feel less trapped between the educational and health systems, as is suggested by the 6 most common interventions required in this population.

Another proactive intervention may be providing additional training to special educators who are certified to teach students with physical and health disabilities. In a survey of these educators, 40% reported that they were not well trained in 11 of 23 critical competencies.31 Although these school professionals have a generally positive attitude about children with chronic illness in their classrooms, they remain concerned with several real risks, most notably medical emergencies (53% of educators) and legal liability (27%).32,33 Another survey of parents and school personnel for children with chronic medical conditions found that there were 5 areas of concern in how these children were managed at school:34 (1) process of how parents informed the school about the child's illness (breaking the news), (2) the processes related to the child's actual reentry into the school (making the transition), (3) the ongoing monitoring of the child's health status that both parents and teachers felt was necessary (watching the child), (4) the need to teach school personnel about unexpected health problems (teaching the teachers), and (5) school personnel's expectations for the child (working with the child). There is arguably an important role for community physicians to fill here, such as helping inform schools of child's condition and working more closely with schools on health status that needs to be monitored. Although it will take some change in how these professionals are trained and reimbursed for this to occur, a higher level of community physician engagement with schools may modify the need for school physician consultation.

Citation: Taras H, Brennan JJ. Students with chronic diseases: nature of school physician support. J Sch Health. 2008; 78: 389- 396.

REFERENCES

1. Child and Adolescent Health Measurement Initiative. 2005. National Survey of Children With Special Health Care Needs. Data Resource Center on Child and Adolescent Health. Available at: www.cshcndata.org/. Accessed January 4, 2007.

2. EURODIAB ACE Study Group. Variation and trends in incidence of childhood diabetes in Europe. Lancet. 2000;355(9207):873-876.

3. Sicherer SH, Munoz-Furlong A, Sampson HA. Prevalence of peanut and tree nut allergy in the United States determined by means of a random digit dial telephone survey: a 5-year follow-up study. J Allergy Clin Immunol. 2003;112(6):1203-1207.

4. McDaniel M, Paxson C, Waldfogel J. Racial disparities in childhood asthma in the United States: evidence from the National Health Interview Survey, 1997 to 2003. Pediatrics. 2006;17(5):e868- e877.

5. Blanchard LT, Gurka MJ, Blackman JA. Emotional, developmental, and behavioral health of American children and their families: a report from the 2003 National Survey of Children's Health. Pediatrics. 2006;117(6):e1202-e1212.

6. DePaepe PL, Doelling J. Supporting students with health needs in schools: an overview of selected health conditions. Focus on Exceptional Children. 2002;35 (1):2-24.

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8. Dorsey L, Diehl B. An educational program for school nurses caring for the pediatric client with a tracheostomy. Training the school nurse to care for a child re-entering the public education system with a tracheostomy. Ostomy Wound Manage. 1992;38(5):16-19.

9. Parette HP Jr, Bartlett CR, Holder-Brown L. The nurse's role in planning for inclusion of medically fragile and technologydependent children in public school settings. Issues Compr Pediatr Nurs. 1994;17(2):61-72. 10. McCarthy AM, Williams JK, Eidahl L. Children with chronic conditions: educators' views. J Pediatr Health Care. 1996;10(6):272-279.

11. Taras H, Potts-Datema W. Childhood asthma and student performance at school. J Sch Health. 2005;75(8):296-312.

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13. Miles-Bonart S. A look at variables affecting parent satisfaction with IEP meetings. In: No Child Left Behind: The Vital Role of Rural Schools. 22nd Annual National Conference Proceedings of the American Council on Rural Special Education; March 7-9, 2002. Reno, Nev. ERIC Document Reproduction Service ED463119.

14. American Academy of Pediatrics, Committee on Children With Disabilities. Provision of educationally-related services for children and adolescents with chronic diseases and disabling conditions. Pediatrics. 2000;105(2):448-451.

15. Martin EW, Martin R, Terman DL. The legislative and litigation history of special education. Future Child. 1996;6(1 ):25- 39.

16. Moses M, Gilchrest C, Schwab NC. Section 504 of the Rehabilitation Act: determining eligibility and implications for school districts. J Sch Nurs. 2005;21(2):126.

17. Betz CL. Use of 504 plans for children and youth with disabilities: nursing application. Pediatr Nurs. 2001;27(4):347- 352.

18. Berman SH, Urion DK. The misdiagnosis of special education costs. School Administrator. 2003;60(3):6-10.

19. Maine School Health Advisory Committee. School Health Manual- School Physicians. Augusta: Maine Department of Education. Available at: http://www.maine.gov/education/sh/school%20physicians.htm. Accessed April 5, 2007.

20. Massachusetts Department of Public Health, School Health, Massachusetts School Physician Committee. 2002. Template for Massachusetts school physician/medical consultant role. Available at: http://www.state.me.us/education/sh/SCHOOLPHYSICIANS06.rtf. Accessed January 4, 2007.

21. Taras HL, Duncan P, Luckenbill D, et al., eds. Health, Mental Health and Safety Guidelines for Schools [guideline 4-04, 4-21] Elk Grove, 111: American Academy of Pediatrics; 2005.

22. Boyce WT, Sprunger LW, Duncan B, Sobolewski S. A survey of physician consultations in an urban school district. J Sch Health. 1983;53(5):308-311.

23. Liptak GS, Weitzman M. Children with chronic conditions need your help at school. Contemp Pediatr. 1995;12(9):64-80.

24. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Strategies for Addressing Asthma Within a Coordinated School Health Program, With Updated Resources. Atlanta, Ga: Centers for Disease Control and Prevention; 2005. Available at: www.cdc.gov/HealthyYouth/asthma/pdf/ strategies.pdf. Accessed January 4, 2007.

25. Kaiser Permanente/American Lung Association National Partnership on Asthma. National Asthma Conference: Asthma Prevention, Management, and Treatment: Community-Based Approaches for the New Millennium. Washington, DC: Kaiser Permanente and American Lung Association 2000.

26. Raina P, O'Donnell M, Rosenbaum P, et al. The health and well- being of caregivers of children with cerebral palsy. Pediatrics. 2005;115(6):e626-e636.

27. Anthony KK, Gil KM, Schanberg LE. Brief report: parental perceptions of child vulnerability in children with chronic illness. J Pediatr Psychol. 2003;28(5):373.

28. Singer, GHS. Family and disability. Res Pract Pen Severe Disabil. 2006;29(2):80-155.

29. Brehaut JC, Kohen DE, Raina P, et al. The health of primary caregivers of children with cerebral palsy: how does it compare with that of other Canadian caregivers? Pediatrics. 2004;114(2):e182- e191.

30. Singer, GHS. Meta-analysis of comparative studies of depression in mothers of children with and without developmental disabilities. Am J Ment Retard. 2006;111(3):155-169.

31. Heller KW, Fredrick LD, Dykes MK, Best S, Cohen ET. A national perspective of competencies for teachers of individuals with physical and health disabilities. Except Child. 1999;65(2):219- 234.

32. Olson AL, Seidler AB, Goodman D, Gaelic S, Nordgren R. School professionals' perceptions about the impact of chronic illness in the classroom. J Sch Nurs. 2004;20(6):359-360.

33. Rehm RS, Rohr JA. Parents', nurses', and educators' perceptions of risks and benefits of school attendance by children who are medically fragile/technology-dependent. J Pediatr Nurs. 2002;17(5):345-353.

34. Kliebenstein MA, Broome ME. School re-entry for the child with chronic illness: parent and school personnel perceptions. Pediatr Nurs. 2000;26(6):579-582.

HOWARD TARAS, MD(a)

JESSE J. BRENNAN, MA(b)

a Professor, (htaras@ucsd.edu), Department of Pediatrics, Division of Community Pediatrics, University of California, San Diego, 9500 Gilman Dr, #0927, La Jolla, CA 92093-0927.

b Statistician, (jjbrennan@ucsd.edu), Department of Pediatrics, Division of Community Pediatrics, University of California, San Diego, 9500 Gilman Dr, #0927, La Jolla, CA 92093-0927.

Address correspondence to: Howard Taras, Professor, (htaras@ucsd.edu), Department of Pediatrics, Division of Community Pediatrics, University of California, San Diego, 9500 Gilman Dr, #0927, La Jolla, CA 92093-0927.

Copyright Blackwell Publishing Ltd. Jul 2008

(c) 2008 Journal of School Health, The. Provided by ProQuest Information and Learning. All rights Reserved.

Source: Journal of School Health, The

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