504 meeting

Guests · Mar 23, 2018

No suggestions but letting you know I feel for you. Is there a school counselor involved? Have other issues been explored yet, like bullying, stress at home, does she feels safe at home? Safe at school? I think if all of these psycho-social things can be ruled out, perhaps a phone consult with the MD who she saw is in order. Is there a report available with an actual diagnosis for her? Ugh, it is a tough situation for you and the school. What state are you in? Do you have a School Health department you could call to bounce questions off of? In MA we have an actual School Health person at the DOH and she is great, perhaps there is someone like that you could contact. Keep us updated.

NutmeggeRN, BSN · Mar 23, 2018

Sounds like anxiety to me...even though we cannot diagnose! I would insist on a release to speak to any and all MDs and/or mental health professionals. And when that is in place, send along their attendance record with these very specific questions?

" Does this child's illness interfere with their ability to attend school?"

" If there is not a physical basis for this, what counseling/psychological evaluations do you recommend?"

" How can I as the school nurse, and we as the school, best meet the child's educational needs?"

It puts it right on the table off the bat. If there is no medical cause, which is the first thing that should be ruled out always, then next steps are psychological and/or educational testing. Too often we are chasing our tails and in the end, it is a there is often a psychological basis to the issue at hand.

WineRN · Mar 23, 2018

Sounds like anxiety to me...even though we cannot diagnose! I would insist on a release to speak to any and all MDs and/or mental health professionals. And when that is in place, send along their attendance record with these very specific questions?
" Does this child's illness interfere with their ability to attend school?"
" If there is not a physical basis for this, what counseling/psychological evaluations do you recommend?"
" How can I as the school nurse, and we as the school, best meet the child's educational needs?"
It puts it right on the table off the bat. If there is no medical cause, which is the first thing that should be ruled out always, then next steps are psychological and/or educational testing. Too often we are chasing our tails and in the end, it is a there is often a psychological basis to the issue at hand.

^^THIS^^

One of the options in the 504 process is to defer the decision until more information is gathered.

But to be honest, if they are this needy towards the school, I can't even imagine how often they call/see the doctor. I wrote about last year how I had a student's family demand a 504 due to the "poor air quality" in the school environment related to the carpeted classrooms. Their doctor wrote an order stating he could only be educated in a carpet free environment. We received the release, and I spoke to the doctor who basically asked me if "I ever met Mrs XX" and that he stood by his recommendation. Even though the little one had never had an asthma attack, barely missed school or had any real medical needs. It was frustrating.

OldDude · Mar 23, 2018

This is a sticky situation. Remember that medical documentation isn't required for a student to be placed in 504. It is the decision of the 504 committee; medical documentation is very helpful of course. So, in the absence of bona fide medical documentation the 504 committee must make it's decision based on their observations of the student while at school. If the committee "sees" what you report above, and if the committee has the "cajones" to take a stand, they can deem that 504 isn't appropriate for the student at this time; especially in absence of any medical intervention recommendations for addressing the issue "while at school." Otherwise, with no medical direction, what would be different if she was in 504 other than to let her stay home from school anytime she wanted to...that isn't a 504 plan. Remember...the parent can attend the 504 meeting but they have no voting privilege.

So, if the 504 committee decides the girl would not benefit from 504 without having some medical framework or intervention plan for school, maybe that would compel the parent to be more cooperative in the reality the situation. I've seen this before and, in some cases, the issue is a Munchausen variant parent.

What you DON'T want to do is give this child or parent carte blanche to stay home whenever they want to because of this "GI issue." They need to provide the medical documentation and plan to the school or there is nothing to do other than the same old song and dance.

Hope this helps...good luck...let us know how it turns out.

mainecoonRN92, BSN, RN · Mar 23, 2018

^^THIS^^
One of the options in the 504 process is to defer the decision until more information is gathered.
But to be honest, if they are this needy towards the school, I can't even imagine how often they call/see the doctor. I wrote about last year how I had a student's family demand a 504 due to the "poor air quality" in the school environment related to the carpeted classrooms. Their doctor wrote an order stating he could only be educated in a carpet free environment. We received the release, and I spoke to the doctor who basically asked me if "I ever met Mrs XX" and that he stood by his recommendation. Even though the little one had never had an asthma attack, barely missed school or had any real medical needs. It was frustrating.

What did you guys end up doing? I know in our district there is not one school without carpet?

nurseinthenorth1 · Mar 24, 2018

Thank you all for the ideas. I have a much better idea of how to prepare for this meeting now. I have also located an ROI form to send to the provider who provided the Rx orders, as well as a "504" medical information form that gives the MD a form to complete to provide a framework for what kind of services or accommodations the student would need. An adult counselor in my town provided a short list of counselors she knows that see children or families, so I will bring that and state my observations about the students lack of interactions with peers and focus on her pets. I think the student feels safe at home and at school, but the student seems to prefer avoidance of anything uncomfortable-I agree, it sounds like anxiety or manipulation of her parent, or, of course, a combination of both...

But I thank you for helping me find a framework to work around-I was a little lost figuring out how to frame my role. We need to get a medical framework and also provide parent with some information about mental health services and frank observations about the benefit of supporting a child to work through difficulties and the confidence that fosters, rather than allow them to avoid anything stressful.

I will let you know how things go down. Thanks again. I'm new to school nursing and I feel it's very important to come prepared to represent ourselves as knowledgeable professionals worth respect, but without experience in this type of meeting, I was needing some help and guidance!

North

ruby_jane, BSN, RN · Mar 26, 2018

I will let you know how things go down. Thanks again. I'm new to school nursing and I feel it's very important to come prepared to represent ourselves as knowledgeable professionals worth respect, but without experience in this type of meeting, I was needing some help and guidance!
North

You are doing a great job!! All the stuff that you told us - kid is normotempive and is not guarding abdomen...robust bowel sounds all four quadrants....all that stuff - document the heck out of it. If the instructions are "for pain," I would ask the student to use a pain scale to rate said pain. I wouldn't NOT give the med but I would again, document the heck out of what I see. It is completely unrealistic to believe that every single stressor will be removed. Good luck!

JenTheSchoolRN, BSN, RN · Mar 26, 2018

You are doing a great job!! All the stuff that you told us - kid is normotempive and is not guarding abdomen...robust bowel sounds all four quadrants....all that stuff - document the heck out of it. If the instructions are "for pain," I would ask the student to use a pain scale to rate said pain. I wouldn't NOT give the med but I would again, document the heck out of what I see. It is completely unrealistic to believe that every single stressor will be removed. Good luck!

Stressors are everywhere! What does the family do at home to provide a stressor-free environment?

Great advice given above.

Side note: If this student truly has a medical need to miss so much school, I may also look into tutoring. In my district, the public schools can provide an outside tutor for up to 4 hours a week if student will be missing more than 14 days of school during the school day due to his/her illness. You be surprised (or not) how minimal the form for it is and how many doctors just sign it and get it approved without noting a specific diagnosis or differential.

nurseinthenorth1 · Mar 29, 2018

Hi All,

We had the meeting today. It was a strange format, I thought. The first thing that happened was that the parent produced some paperwork about all the obscure diagnoses that the student carries (Cyclical Vomiting Syndrome, Spontaneous Joint dislocation syndrome, Functional Abdominal syndrome... and the like), in addition to ANXIETY! Everyone then agreed the student qualified for a 504, then we proceeded to talk about how her diagnoses affect her daily life activities. I thought it was weird that nobody asked about these diagnoses, because after all, there are a lot of kids in our schools who carry diagnoses, but don't need a 504. I also thought it was weird that we approved her for the 504 before we talked about the health and living affects of her illnesses. Her teacher got brave before anyone else when talking about the accommodations she is already providing for the student (noise cancelling headphones to help deal with the stress of noise) and pointed out that the student is often making farting noises with the headphones already and needing 45 minutes to fix her hair before placing the headphones on her head and getting to work.

We talked extensively about the student's attendance - 50%. Nobody on the 504 team had seen the medical evaluation form for her doctors to fill out from our district. I asked the parent why she thought the student has never vomited at school in the 2 years I've worked there, and yet is home almost half the time this year with "severe vomiting". Parent claimed students illness is unusual and not predictable.

Overall it was a bizaare experience, but I was glad the teacher stood up for herself in how the student is manipulating her accommodations and was glad that it was made very clear to the student that these accommodations are for her to use and not abuse. I wish I would have asked why we were approving the 504 plan before discussing the affects of the student's medical diagnoses-who knows about cyclical vomiting syndrome right off the top of their head? I wish we could have deferred a decision until we hear back from her medical providers, rather than just taking parent at her word. I was also glad to hear she's getting counseling for her anxiety-I brought up my thought that the student's stomach may be hurting because she has an uneasy feeling and is anxious and we all want to avoid things that make us feel like this...

We'll see how it goes. This will at least give the students teacher next year a formal process to go through rather than having to start all over with this parent as well as a way to enforce not getting manipulated into all kinds of other taxing things. I don't feel like the process got any closer to helping the student succeed academically or emotionally. We'll see. It was a great learning process. I'm wondering if anyone has any information about 504s and their legal process (wondering about whether we should have approved the plan prior to consideration of what we were approving)... Thanks all for the conversation and space,

North

ruby_jane, BSN, RN · Mar 29, 2018

Hi All,
We had the meeting today. It was a strange format, I thought. The first thing that happened was that the parent produced some paperwork about all the obscure diagnoses that the student carries (Cyclical Vomiting Syndrome, Spontaneous Joint dislocation syndrome, Functional Abdominal syndrome... and the like), in addition to ANXIETY!

I find it interesting that the administration allowed 504 accommodations without a current MD note. Also I love it when teachers document like nurses and are able to demonstrate when the plan is worked or when student is working the plan. Also sooo interesting the CVS only happens "at home." Hang in there!

JenTheSchoolRN, BSN, RN · Mar 29, 2018

I find it interesting that the administration allowed 504 accommodations without a current MD note. Also I love it when teachers document like nurses and are able to demonstrate when the plan is worked or when student is working the plan. Also sooo interesting the CVS only happens "at home." Hang in there!

You don't need an official note to create a 504 plan at school in many states. However, official documentation is needed in my state for state testing (i'm in MA, so MCAS) and other testing such as SAT, AP, and ACT if the student receives testing accommodations. (504 plans can also travel with a student to college. Not everything will be granted, usually extra time and small group testing.)

A 504 plan is accommodation based vs. academic modifications (IEP) and the parent or teacher alone can call for a meeting if they feel the student needs extra support. The paperwork the doctor submitted with possible medical diagnosis is enough to proceed. One can debate the need for them, but guidelines can also be written in about proper use of accommodations. I hate to type this, but I have many students I suspect that know what their 504 plans says and use it to play the system more than they should.

I go to a lot of 504 meetings and I actually write up the purely "medical" 504 plans - i.e. the ones I have in place for diabetic students that don't involve really any additional academic supports. (Student is still assigned a SPED liaison, but I still handle emailing teacher if student is high and unable to take a test, for example). I learn new stuff about 504s all the time :).