Collaborating With Physicians: A Guide for Educators
By Steven R. Shaw, PhD, NCSP, Mark C. Clayton, MD, Jodi L. Dodd, PhD, & Ben T. Rigby, PhD
Sooner or later, most educators will work with students who have significant medical or health problems. Finding ways to support these students can be enhanced by developing a collaborative relationship with the family’s physicians or other healthcare providers.
Unfortunately, sometimes educators find themselves in an adversarial relationship with healthcare providers. For example, a physician might demand that the school provide special education or therapeutic services. In such a situation, educators may view the physician as arrogant, disrespectful of school policies, or ignorant of school law and regulation.
Yet, sometimes physicians receive notes from teachers or principals demanding that they prescribe medication for a child due to behavior problems or receive a copy of an Individualized Educational Program (IEP) filled with educational and legal jargon. Physicians might then view the educators as practicing medicine without a license, providing information irrelevant to children’s medical issues, or misinforming parents. These charges may contain a grain of truth. However, such perceptions often interfere with the development of a potentially important relationship between educators and physicians.
Physicians and educators use two different but parallel systems of diagnosis, service delivery, and treatment. Although there are many differences, there are just enough similarities between the two systems to create confusion for all professionals and parents.
Physicians use the International Classification of Disease (ICD-9) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR) criteria for making diagnoses. Educators use the guidelines stated in the Individuals with Disabilities Education Act (IDEA), refined by regulations in each state, and implemented by each local educational agency.
Using dual systems. The confusion comes into play, for example, when a physician diagnoses a learning disability and educators find that the same child is not eligible for the learning disabilities classification within the special education system. Perhaps a physician requests educational assistance for a child with attention deficit hyperactivity disorder (ADHD), yet educators do not believe special education services to be appropriate because there is limited evidence that the child’s academic performance is impaired by ADHD. So who is right? Actually, both are. Physicians are making correct diagnoses and treatment recommendations based on ICD-9 or DSM-IV TR and recommending a medical model approach to treatment. Educators are correct in using state criteria for disability classification, local procedures to implement IDEA, following legally and educationally appropriate safeguards, and developing an effective educational treatment plan.
Individual versus team diagnosis. Physicians make individual diagnoses. Educators determine special education eligibility through team decision making. Physicians do not use prereferral interventions, resistance to intervention models, or often consider children’s functioning in the context of the classroom. Educators rarely consider family history, neurological findings, or lab results. The educational and medical models contain enough similarities to create confusion and enough differences to create conflict. Yet, both seek the same goals.
Teamwork. How can professionals using two entirely different systemic approaches to diagnosis and service delivery work together? The first step is for both professions to understand that there are two equally legitimate and valid systems in place that can work together. The second step is to appreciate that in many cases neither physicians nor educators can provide effective services to children alone. Teamwork is a requirement and not simply a refinement.
Model for Effective Collaboration
Respect professional boundaries. The first stage of collaboration is to respect the formal boundaries of the medical and educational professions as established by state certification and licensure laws. Physicians must refrain from dictating school educational placement decisions or educational techniques. Schools must refrain from suggesting medication decisions or making medical diagnoses. However, information can easily go across formal boundaries. For example, a teacher may state, “Since Jane started taking her medication, she has begun falling asleep in class.” Or a physician may state, “Since Jane started in the gifted class, she has had severe abdominal pain with no known medical origin.” Although information sharing is important and needs to be encouraged, professional judgment and decision making about how to apply this information should be left solely in the hands of the appropriate professional.
Invite participation. Although respect for formal boundaries is important, there also must be an informal reaching across barriers. There are few activities that act to develop interdisciplinary relationships as much as a physical presence. When teachers take time out of their busy schedules to accompany children to a pediatrician visit, they demonstrate a significant commitment to working as a collaborative team. When a physician takes time to attend an IEP team meeting, the commitment to the collaboration is equally clear. Tight schedules and pressures to earn clinical revenue make personal appearances difficult. Taking the initiative to invite other professions to participate is one of the best ways to reach across barriers without the time demands of a personal appearance. For example, teachers should be involved in the evaluation of efficacy and unintended effects of medical management of behavior. The pediatrician should be asked to review the IEP for any activities that may be medically contraindicated.
Communicate effectively. The basics are also important. Return phone calls in a timely manner. Make yourself available. Write jargon-free reports and letters. Ensure that parents have completed all appropriate release forms and understand the nature of the collaboration before it begins. Most parents believe that such an interdisciplinary relationship can only help their child. However, some parents choose to keep medical and educational issues entirely separate. The parent’s right to such a separation must be honored.
Use liaisons. Because medical and educational systems have such different vocabularies, it may be wise to use a medical–education liaison as a translator so that both professions understand what the other means. Hospital-based teachers, school nurses, social workers, school psychologists, and others with training in both medical and educational environments are good choices.
Present the facts. There will also be times when you will be expected to present your findings. Adopt a medical model of case presentation. This often serves to help organize large quantities of information into the pertinent positives and negatives. In other words, leave out all judgments and even extra information that is important, but not critical, to what needs to be addressed by the physician. Case presentations should include:
- The patient’s name, age, ethnic origin, sex, and reason for referral in the opening statement
- All relevant historical findings (i.e., birth trauma, history of brain injury, developmental delays, academic progress over time, or placement in a special education curriculum)
- Relative weaknesses and strengths of the child as determined by your observations compared
to other children in the class
- Behavior, cognitive, social, and academic requirements of the classroom
- The top three to four recommendations that address an immediate plan for how to help the child given the evaluation results. There will likely be more than three or four total recommendations in the report, but, remember, your main goal is to communicate interventions that need to be addressed by the physician. A quick statement regarding the other areas addressed in your recommendations might be helpful (i.e., “Several suggestions were made regarding IEP goals that might help this child improve her handwriting.”). This assures the physician that the more systemic issues are receiving attention.
ADHD: An Example of Physician/Educator Collaboration
One of the differences between educators and physicians in aiding children with ADHD is the inherent conflict between addressing the needs of all of the children in the classroom versus those of the targeted child. The prevalence ADHD is believed to be 8–10% of the population. Therefore, for a class of 25 students, we can expect 2 or 3 students to have ADHD, assuming it is a regular education classroom. That number clearly increases in special education settings.
However, for physicians, especially pediatricians, ADHD issues are among the most common reasons for an office visit. Given the limited time available to the physician to address the child’s and family’s concerns, it is not uncommon for physicians to provide cut-and-paste behavioral and educational recommendations or responses for challenging issues in the home, community, and classroom. Therefore, communication from teachers and or other school personnel should include informing local physicians, in a general manner so as to not betray confidentiality issues, what types of interventions or accommodations have been useful or partially successful and what types should be deferred.
Medication trials. Physicians’ approaches to medication trials vary, depending on training and experience. Some physicians will advocate not informing the school that the child is taking medications, hoping that the child’s teacher will recognize when a particular medication or dose results in significant improvement in either core ADHD symptoms or academic performance. Other physicians, however, will want the child’s teacher to make frequent assessments concerning the child’s response to a particular dose, including at select times of the day. Because children and adolescents can show significant variability in their response to a particular dose, teachers may be called upon to make observations for several weeks in a row as a medication or dose is titrated.
Symptom overlap. One of the issues that may postpone a diagnosis of ADHD in a child is the overlap of symptoms with other disorders, including medical problems, anxiety, depression, learning disorders, and dental pain. To make an accurate diagnosis, it is critical to address or rule out other conditions before making a diagnosis of ADHD. In addition, even when children demonstrate the requisite symptoms necessary for a diagnosis, information about the degree of impairment in settings outside of the classroom sometimes can be difficult to acquire from families. Furthermore, the presence of some symptoms at a clinically significant level has been recognized as occurring with relative frequency in the general population.
Parent and teacher communication. Parent and teacher agreement can be modest at best and includes differences observed in disruptive behaviors (e.g., hyperactivity, impulsivity, emotional lability) and cognitive/executive function behaviors (e.g., inattention, organizational difficulties, working memory). Such differences can create frustration for clinicians, especially those who may rely on rating scales to help with diagnostic decisions instead of using the information to look for an overall consensus that there is a problem. Educators should be aware that often there is a difference in the observations made by each parent, which can also contribute to frustrations in concluding that there is a neurodevelopmental disorder rather than a curriculum mismatch or parental psychopathology. Yet, differences among respondents are to be expected. Different adults place different demands and challenges on children.
Comorbidity and ADHD. A high degree of comorbidity has been documented in ADHD. Many reports suggest that about 70% of children diagnosed with ADHD will have another diagnosis. Depending on the type and severity of the comorbid disorder, a physician may choose to have the child start treatment or even seek further evaluation for the other disorder instead of ADHD. Several childhood disorders, including those involving mood, anxiety, or other disruptive behaviors (i.e., oppositional defiant disorder/conduct disorder), have symptoms similar to those of ADHD, and a clinician may delay giving a diagnosis of ADHD until further evaluation has determined whether such other diagnoses are more appropriate.
Nonmedical treatments first. Depending on a physician’s training, availability to continuing medical education, formal academy policies, or even personal philosophy, some physicians may recommend behavioral counseling and/or psychoeducational testing before initiating medication treatment. However, this can create a delay in prescribing stimulant medication, even if likely to be an appropriate therapeutic option, given both the limited number of therapists/assessors and a probable waiting list.
Parents’ expectations. Parents who suspect their child has ADHD do not tend to come to a physician for diagnosis alone. They also expect education about the disorder as well as practical suggestions for coping with behavioral issues and empathy and comfort to address any feelings of guilt regarding the cause of the child’s problems. Although it is part of the physician’s role to assess the family’s readiness to receive this information, both cognitively and emotionally, it is easy to fall into the trap of assuming that the parents know little about the disorder.
This assumption unfortunately can naturally extend to the child’s teacher, particularly when the parents’ frustration with the child’s performance is interpreted as a lack of empathy or willingness to be informed on the teacher’s part. Conversely, because physicians may not have information on possible school interventions, including IEP or Section 504 responsibilities of the school, it is easy for the physician to assume that the child’s teacher and school will inform the parents of such options and faithfully represent the child’s best interests. Physicians may also be unaware of local budgetary or personnel constraints in providing appropriate interventions or resources.
Collaboration between educators and physicians can be an exciting and highly rewarding experience. When all players within the assessment team work together, the child ultimately reaps the reward. Following these simple tips—educating ourselves as to the needs of various professions and building strong working relationships that are based in mutual respect and clear communication— will help to improve the overall quality of a child’s care.
Drotar, D. (1995). Consulting with pediatricians: Psychological perspectives (Issues in child clinical psychology). New York: Plenum.
American Academy of Pediatrics, www.aap.org/family
Pediatric Development and Behavior, www.dbpeds.org
Adapted from Helping Children at Home and School II: Handouts for Families and Educators, NASP, 2004