Doctor's note for "Chew Toy"

Jolie, BSN · Oct 27, 2016

I don't understand how this is a nursing issue. It does not involve assessing the student's health, planning nursing interventions, administering medications or treatments or evaluating outcomes.

It sounds to me like this is an educational/behavioral issue that is essentially being addressed by allowing the child to have a "security" object, and is appropriately handled by the teacher/counselor.

The only concern that is even remotely health related is the cleanliness of the ring. The teacher can manage that, just as s/he keeps other classroom items clean.

GmaPearl BSN RN · Oct 27, 2016

Jolie is correct. Accommodations for the child's sensory needs would most appropriately be managed by the teacher and the school's OT.

oceanblue52 · Oct 27, 2016

I was a behavioral therapist for a bit before becoming a nurse, and agree with this not being your problem. However, I think it's admirable that you are trying to get this issue addressed. Having a chew toy is very helpful for some children and can decrease disturbances in the classroom. Is there a behavioral specialist in charge of the IEP? Somebody needs to add it to the plan because it is a good preventative measure. Is the primary caregiver aware? I don't know enough about IEP meetings but surely somebody can be informed to add it. You are an important advocate in the school setting. And honestly, I've been in classrooms, teachers have a hard job but it's not that difficult to wash a mouth piece. Would like to hear what other school nurses have to say as I'm speaking from a different perspective.

kummerspeck · Oct 27, 2016

Precisely what oceanblue52 said above. You are an advocate for the students there. If it is not a part of the IEP, then a meeting can be held (have the parents request it, if need be) so that this accommodation can be added to it. Or have a section 504 written for the accommodation of the chew toy. I used to be a teacher and this would have been what I advocated for the student. It's not really up to you whether or not he gets to use it, his doctor prescribed it, and these items can be very beneficial to these kids. I would have also, as the teacher, discussed with my other students about how their classmates all learn in different ways, and eventually, they would stop worrying about what he was doing and concentrate on their own business. I used to have students who had to stand in order to do their work, or wander in the back of the room, or use a myriad of devices to control their anxiety, etc, in the classroom. And it's easy to teach hygiene practices with it so the kid knows when/how he should clean it. Good luck!

BeckyESRN · Oct 27, 2016

We have several student with "chew toys". Our OT has provided these kiddos with what is basically a teething necklace, so it looks more like jewelry than a "chew toy". The cleaning recommendation for the teacher is just to rinse when needed. While it may be a bit of a distraction at first, once the other kinders are used to it being there, they will forget about it. I think it would be extremely unreasonable to the district not to comply with this order. It's a simple thing that may help the child over all.

clockwood · Oct 27, 2016

Thank you all for your input. Our area administrator said she thought the letter from the doctor was ridiculous and asked me to discuss it with him...??? I thought that was pretty funny.

I agree that this is a behavior/OT issue. My goal is always to advocate for the child...with that said, I do believe that weaning the child off of the chewy and integrating a behavioral plan that emphasizes "appropriate" coping strategies is 100% within this child's abilities. That is my "team" input, however it may not bear much weight as I am not a behaviorist, nor and OT :)

Does anybody know if the school district legally has to comply with the note? I'm just curious.

JenTheSchoolRN, BSN, RN · Oct 27, 2016

As folks have said up thread, this is something that should become part of the student's IEP and/or 504 plan. The goal for its use and weaning could be a goal on the IEP, but would be determined and managed by an OT at my school. I'd have nothing to do with it, except keeping the doctor's note on file and helping teach the student how to keep it clean if needed.

Folks may think it is ridiculous, but I'd likely tell that person this: "It a tool that means the child can effectively learn without being disruptive to the rest of class. Isn't that the goal we all want? But it is not in my scope to manage its effectiveness as I am not a behavior specialist, so any discussion with the doctor about its use it best left to [our] OT/etc." [i'm sure you already told them something along the lines of that :).]

I've offered feedback to our OT and counselor for student's IEP goals if I have feedback appropriate to their goal; they have always appreciated it. I typically don't attend IEP meetings (just 504 meetings), unless I have a specific medical need to be present.

NutmeggeRN, BSN · Oct 27, 2016

Thank you all for your input. Our area administrator said she thought the letter from the doctor was ridiculous and asked me to discuss it with him...??? I thought that was pretty funny.
I agree that this is a behavior/OT issue. My goal is always to advocate for the child...with that said, I do believe that weaning the child off of the chewy and integrating a behavioral plan that emphasizes "appropriate" coping strategies is 100% within this child's abilities. That is my "team" input, however it may not bear much weight as I am not a behaviorist, nor and OT :)
Does anybody know if the school district legally has to comply with the note? I'm just curious.

I believe that MD orders for such things are recommendations but cannot be forced upon the district.

PG2018 · Oct 28, 2016

I believe that MD orders for such things are recommendations but cannot be forced upon the district.

No. I get requests all the time to prescribe some type of object, service, or policy so the schools will have to comply. I tell the parents/patients/guardians that it's not my circus. I don't do court recommendations or service animals either.