Lecture # 115:
Other Health Impairments

copyright 2008 Cheryl K. Hosken, BSN, MS Psych.

Objectives:
1. The student will become familiar with the conditions of "other health impairments".
2. The students will be able to identify the stages of HIV.
3. The student will know how to help children who have a classmate who is dying.
4. The student will know what substances cause impairments to a fetus.

HIV / AIDS
Personal History
David and Douglas are 4.5-year-old twins who were born with HIV. Summer has just begun for them, but they are eagerly waiting for fall, because then they will go to the "big school" across the street from their home. Even through their days are busy and full, they want to go to school with their big sister Angela. But summer vacation has started and they will learn how to swim at the pool.

Today is typical for David and Douglas. Their mother, Anna, comes into their bedroom at 6 a.m. and gives them their first dose of medicine for the day. Both boys swallow the sticky liquids without complaint. They have taken a lot of medicine since they were first diagnosed with HIV two and a half years ago. The boys accept it as part of daily life, like brushing their teeth every day. At 7 a.m., they begin their morning routine: eating breakfast while watching cartoons. Their mother is proud of them, despite their problem, they are healthy and active.

After breakfast, they dress and play outside. By the middle of the morning they are ready to come inside to get out of the heat. Today their mother is babysitting her friend's child. The boys help with feeding her.

At lunch, Douglas gulps down his second dose of medicine. Anna has not told the boys they have HIV. "They are too young to understand", she says. "They do know they have to take medicine to stay well." Both boys are good eaters and finish their hot dogs, cookies, and milk at lunchtime. An HIV support group provides these meals. Anna, who also has HIV, appreciates the way this service helps her conserve energy and finances. "I am fine now, just a little tired," she says. "And even if I didn't have HIV, I would be tired." Raising twins is a big job for a single parent.

Meditate Word By Word On These Verses:
James 2:5-6.

Today, Douglas has his monthly intravenous immunoglobin therapy, a nurse comes for this shortly after lunch, and Douglas sits in an easy chair, plays quietly and watches TV while the medicine flows through the plastic tubing into his veins. He does not complain. He prefers to get the intravenous medicine at home rather than going to the hospital. These treatments, along with antibiotics, are helping Douglas. In the past year, Douglas was hospitalized four times for pneumonia. This year, he has avoided the hospital.

David's immune count cell is too low. His doctor has changed his medicine so that he takes something stronger and only twice a day. He cannot have anything to eat for one hour before and after taking the medicine. In the evening, they play games with their sister.

Just before falling asleep, David asks Anna if he can visit the video game room tomorrow. He loves playing video games.

No one isolates or makes excuses for David and Douglas. Anna treats them as normal children, but she knows their lives may be limited. Meantime, she provides the best opportunities she can for them.

Question:
1. How is HIV affecting the mother, David and Douglas, and their daily routines?

What are Other Health Impairments?
After reading about Douglas and David, you can probably understand why they qualify for educational services that cover health impairments. However, not all health impairments are easy to identify as those that afflict these boys.

From the example of David and Douglas, we can see that people who receive educational services vary greatly in their educational, social, medical, and emotional needs. Some have severe incapacities; others are rarely affected by their condition. Some experience pain; others are free of any symptoms of illness. In some cases, the condition is life threatening. In others, the individual can lead a long life, and death will come from some other cause.

Students with health impairments also vary in their cognitive and social skills. For example, one person with asthma might be gifted; another could be a slow learner. One student with cancer receives support and comfort from loving family members; another spends lonely days and nights at home or in a hospital.

Definition of Health Impairments
The legal definition of health impairments is as follows: Having limited strength, vitality, or alertness due to chronic or acute health problems such as a heart condition, tuberculosis, rheumatic fever, nephritis, asthma, sickle cell anemia, hemophilia, seizure disorder, lead poisoning, leukemia, attention deficit/hyperactivity disorder, or diabetes that adversely affects a child's educational performance.

The three major criteria affecting these children are strength, vitality, and alertness, which increase their need for educational assistance. David and Douglas, at various times in their lives, will experience limitations in their strength and vitality. Unless, researchers find a cure for AIDS, Douglas and David will eventually die of their infection.

The conditions affecting children can be chronic or acute. A chronic condition develops slowly and the symptoms are long lasting. An acute condition develops quickly and the symptoms are intense, but the condition lasts for a relatively short time. Although asthma is a chronic condition, asthma episodes are often acute because the symptoms develop and subside suddenly. However, HIV is chronic. The symptoms can progress over a period of years and are ongoing. Attention deficit disorder may be a chronic condition lasting through adulthood, but sometimes children's attention deficits decrease with time.

Question:
2. How do health impairments affect strength, vitality, and alertness of a child?
(Only one of the following answers is correct.)
a) Because health impairments are chronic.
b) Because health impairments make a child's health unstable.
c) Because health impairments can be fatal.

Characteristics of Health Impairments
Other than having limitations in strength, vitality, and alertness, children with health impairments have few common characteristics. Therefore, we will describe the characteristics of children with HIV/AIDS, cancer, prenatal substance exposure, asthma, seizure disorder, diabetes, and attention deficit-hyperactivity disorder.

Many of these children are more like other children than different. Even if the child has some limitations, he usually can attend regular class. Often times, they do not need special educational assistance, but for others changes in curricula, methods, and classroom routine are needed.

Human Immunodeficiency Virus
Children with HIV usually take medications every day; the number of times and types of drugs depend on their symptoms and blood tests which are done once a month or more often. If breathing becomes a problem, it is probably due to pneumonia, which can cause death if not treated immediately. Some of these children are angry, but most are afraid of needles, procedures and death. Along with these medical problems there are social problems of HIV.

Some people say awful things about the mother of a child with HIV. Why did she have a child? Didn't she know that HIV could be passed on to her children? Didn't she know she had HIV? The difficulty is that HIV has a "quiet" latency stage and a woman may become pregnant and not know that she has HIV virus in her blood. The latency period can be from 6 months to several years before symptoms make an infected person go to a doctor.

Here is the experience of one boy, Ryan White. He got HIV from a blood transfusion when he was being treated for hemophilia.

I had a good year before, even though I had to fight for the right to go back to school. (He already had HIV.) People in my hometown tried to keep me out because I have HIV. People in town thought I could give other kids HIV if I kissed them or sneezed on them, or if I dripped sweat or tears on them. That is disgusting to me. I would never do that!

Panic spread all over the school. Lots of times, kids flattened themselves against the walls of the corridors when I walked by. I heard kids telling jokes about me. And grown people passed along lies about how they saw me biting people or spitting on vegetables in the grocery store. I never did and I never would.

When I did get back to school, a lot of people did not want me there. Someone fired a bullet into our living room window. So my mother, sister, and I moved to a different town. People there were much more understanding. (Ryan White died of AIDS in 1990.)

Question:
3. Discuss AIDS: Why do you think there is such a disease? Do think this could be God's judgment on people? What are the social implications of millions of children in Africa who are without parents to raise them, because their parents have died of AIDS?

HIV is a condition that gradually destroys the immune system of the body, in particular it destroys the T4 immune cells. With the destruction of the T4 cells, the body is increasingly vulnerable to infections.

As the virus progresses in the body, a person is more susceptible to opportunistic infections. Usually the bacteria and viruses we have in our bodies can be destroyed by the T4 cells, but without T4 cells, the body becomes a place for infections to grow. The most common infections are some cancers, fungus infections (such as athlete's foot, thrush), pneumonia, and tuberculosis.

Stages of HIV
HIV progresses through distinct stages. Increased levels of illness and severity of symptoms mark the progression of the disease. People in the earliest stages of HIV, called the latency stage, have the virus in their bloodstream, but do not have any outward symptoms of illness.

Anna's infection was in its latency stage when doctors diagnosed her with HIV. She had not been feeling sick, but the doctor wanted to check her. He suspected that she had HIV because Douglas had just been diagnosed. Anna was really surprised at the results. Two-thirds of the children born with HIV do not have any symptoms initially. Usually when they are a little older, at the age of two to five years, they begin to experience symptoms. Those people who get HIV through blood transfusions might remain symptom free for years.

In the middle stages of HIV, the virus reproduces more actively, the immune system begins to lose its effectiveness, and people begin to experience minor symptoms. A common symptom is fatigue; other middle stage symptoms include persistent fevers, night sweats, chronic diarrhea, recurring vaginal yeast infections, and swollen glands. As their immune system weakens, people in the middle stages begin to have more frequent illnesses and opportunistic infections.

In the final stage, which is known as AIDS, the infections increase in severity and frequency. Symptoms often include seizures, lapses in memory, impaired vision, blindness, and in children, the loss of cognitive abilities. Eating is usually difficult and the body's ability to use the nutrients in food is affected, which contributes to severe weight loss seen in people with severe infections. Cancerous lesions and lung infections are common. Antibiotics and antiviral drugs have minimal effect because of the low T4 cell count. Pain is severe and death is imminent.

The definition of HIV progressing to AIDS is when a person's T4 cell count is 200 or less per milliliter of blood. For five year olds, the normal T4 cell count is 1,700 per ml. When David and Douglas' mother was interviewed, Douglas' T4 cell count was 958 and David's was almost no T4 cells. David's doctor had changed medicines to try to improve his resistance to infections.

Match these terms with the definitions below:
A. Latency Stage, - B. Middle Stage, - C. Final Stage.

4-1. The common symptom is fatigue, but there may be swollen glands, fevers, and frequent infections.
A, B, C.

4-2. Symptoms of blindness, seizures, weight loss, lung infections.
A, B, C.

4-3. No visible or bodily symptoms.
A, B, C.

HIV in Schools
Transmission of HIV
There are two major issues related to HIV in the classroom: 1) to prevent the spread of HIV in school, 2) to know how the HIV can affect learning and behavior. The first issue has brought about what is called universal precautions. By using these rules, the spread of HIV or any infection is minimized. There are four precautions:

HIV does not appear to spread through casual contact, that is, living in the same household with the infected person. If the student's behavior or medical condition (biting, open sores) is clearly inappropriate for school, then he needs to be taught at home. Also, if the child's immune system is low, he should not be in school where he could become ill from other children's infections.

The second way to prevent the spread of HIV is by giving other students in the school the facts about the disease and how it is spread. A curriculum that includes general knowledge of the disease, personal relationships, sexual development and responsibility, drug abuse, and personal growth will give other students the knowledge they need to be careful with others and with their own bodies.

Students with HIV
Children with HIV do not differ from other children in intellectual functioning for about 4.5 to 8 years after infection. There are differences between children with HIV and children without HIV in that they have some "slowing of motor speed (agility) and impaired attention and concentration". In the studies done the differences noted were minimal and not seen in every child with HIV. David's ability to play video games has certainly not been affected by the virus.

Question:
5-1. Do you think children with HIV should attend school?
yes / no.

5-2. Why?

Prenatal Substance Exposure
What is it?
We have already read how a mother can transmit HIV to her child. The mother's use of alcohol or drugs can also affect the well being of her unborn child. Such children have a higher risk of developing learning disabilities or behavioral problems than the general population. The drugs can be prescription or illegal, and nicotine is included. The period of time during pregnancy when a mother ingests drugs and the frequency of ingestion can affect the child's risk of having symptoms.

Definitive characteristics can be observed in some children exposed to drugs or alcohol, which can be observed at birth, during infancy, or in grade school. It is also important to remember that the child is also affected by his psychosocial conditions. Some children are in families where there is multigenerational substance abuse, poverty, or living with adults whose main goal is to find drugs for their habit.

At or Before Birth
The mother can cause health problems for her unborn child by drug use. Complications at birth can also happen to the drug-abusing mother. The child's health, ability to learn, and behavior can be affected. Despite the risks though, many children of drug-abusing mothers have a normal birth and no physical abnormalities.

One of the results of alcohol abuse during pregnancy is the birth of a child with Fetal Alcohol Syndrome. A syndrome is group of symptoms associated with a certain condition. Children with fetal alcohol syndrome tend to remain small after birth, have drooping eyelids, facial deformities - wide nose and flattened mid-face. A small head size is also common. Internally, the children have heart defects and mild to moderate mental retardation.

Fetal alcohol syndrome is not predictable. Mothers who chronically drink have normal children 50-70% of the time, while mothers who drink only occasionally may have a child with fetal alcohol syndrome. It has been noted that children with this syndrome are affected within the first three months of gestation. Therefore, if a woman of childbearing age wants to become pregnant, it is important that she abstain from alcohol or drugs.

During Infancy
Most infants with prenatal substance exposure do not differ significantly from other infants in physical developmental comparisons. Of greater concern are the neurobehavioral characteristics of some of these infants. Such characteristics include their irritability, difficulty in handling them for bathing, feeding, and diaper changes. There may also be high-pitched crying and unresponsiveness to attempts to comfort them.

Children who are unresponsive and difficult to manage are generally more at risk for abuse or neglect from caregivers. Even the most stable parents and relatives find that caring for such a child challenging. The child does not fit their expectations and is irritating. However, these characteristics may be true of the child without prenatal substance exposure.

Later years
Children with prenatal substance exposure can be divided into three groups: a) those with developmental disabilities including seizures, physical abnormalities, or mental retardation, b) those with normal development, c) those at risk for having learning and behavior problems. The majority of children with substance exposure will have normal development, but approximately 30-40 percent of them have delays or attention deficits. They may develop any or all of the following problems:

Therefore this group may need special educational programs. Again, early intervention is important to minimize the effects of the substance exposure.

Question:
6. Children who have been exposed to drugs or other substances before birth:
(One or more of the following answers may be correct.)
a) may have increased risk for abuse because of their irritability.
b) always have some type of disability.
c) may have problems with learning in school.

Professionals can Help These Children
One girl, almost three years old, arrived at preschool balky and whiny. Anything she found on the floor, she put in her mouth - crayons, buttons, coins. She wet her pants and refused to lie on a cot at naptime. Instead of trying to fit a puzzle together, she threw the pieces across the room. When she spoke at all, she said one word - "car," or perhaps "door."

After four months in the nursery, in a classroom with ten children and four special education teachers as well as regular sessions with the speech pathologist and the psychiatrist, the girl still has difficulty focusing on a particular task. However, she will work on a puzzle for five minutes before leaving it and says five word sentences now. She can follow what is happening in a group and she understands when activities begin and when they end.

Asthma
Asthma is a condition that affects the lungs and causes breathing difficulties. Some people have only occasional symptoms and others have breathing problems almost every day. Mild symptoms may be shortness of breath after a football game, or they may be life threatening.

Asthma is the most common lung disease among children and begins in before the age of three in 50% of cases. About twice as many boys as girls have asthma, and boys are more likely to have severe asthma. The general tendency with boys is for asthma symptoms to decrease as they grow older, and for girls to have more problems as they grow into adolescence. There are three primary features of asthma:

  1. Airway linings (bronchi, lungs) are swollen
  2. Airways narrow, and breathing becomes difficult. This narrowing may reverse itself, or be reverse with drugs.
  3. Airways are supersensitive. They react to a variety of stimuli including physical changes (cold air or exercise), allergens (cat and dog dander, dust mites, molds), and irritants (smoke, strong odors, and sprays). Coughing, wheezing, or difficult breathing may result from this exposure.

An asthma attack is usually mild, but it can also become severe causing a medical emergency. The child may be approaching an emergency if:

Asthma in School
Medications - The child who has mild symptoms may have bronchial dilator inhaler or medication. The child with severe symptoms usually has daily medications.

Lung Function - To monitor lung function, a peak flow meter is used. This is a simple device with a mouthpiece and the child simply exhales as hard as he can. The higher the reading, the better the lungs are working. A lowered reading indicates that the airways are obstructed and the child needs medication or must leave an area where allergens are present.

Managing Stress - It is important to remember that asthma is a disease of the lungs and not of nervousness. There is fear and panic if a person cannot breathe, but fear and panic do not cause asthma. Relaxation techniques help a person respond to episodes of asthma once the symptoms begin. Deliberate self-calming activities help avoid additional constriction of airways and help the person while he waits for his medication to take effect.

Many asthmatics live normal lives since they have learned to control their symptoms and take medications that will relieve them of symptoms. Many enjoy sports of all types.

Students must be careful to understand what is the trigger for the asthma in the environment - dust, smoke, cats, dogs, etc.

Cancer - Leukemia
What would be your reaction to hearing that you have cancer? A teenager shares her feelings:

It started in 1989. I didn't think that anything was seriously wrong. I just didn't feel very well, but I was sure it was the flu. I was frightened of all the tests the doctors were doing, not because I believed something was wrong, but because I hate needles and hospitals.

My mom knew what testing was being done and she was more frightened than I was. She told me that the doctors were checking for two things - leukemia and hepatitis. I just laid there and cried. When I went for biopsy, I could not stop crying. I thought the doctor would be angry with me, but he was nice and patient.

The next doctor I saw was my oncologist. He said that I had Hodgkin's Disease. He explained that he wanted to fight it and how he would do that. We started chemotherapy right away. He said that I had a 60% chance of living and 40% chance that I would have children. I cried for the children that I might not have.

I stated chemo and tried not to think about what was happening, I laid on the bed and was given a tranquilizer and sedative. I slept. I was not afraid of dying, but what might happen to me before I died.

What is Cancer?
Cancer is an unrestrained growth of cells in body organs or tissues. One third of children who have cancer have leukemia - cancer of the blood cells. Although rare in children, this form of cancer as a rule causes death when it affects young people between the ages of one and fourteen.

The good news is that through combination therapy, the survival rate for children has dramatically improved. The survival rate for childhood cancers is 68% and for leukemia is 88% for Hodgkin's Disease. Unfortunately, the treatments for cancer generally cause side effects. Chemotherapy works on all rapidly dividing cell and adversely affects hair growth, bone marrow, intestinal lining, and the mouth. In addition, the treatments lower the white cell count and increases vulnerability to infections from other people.

Cancer at School
Children with brain tumors and radiation to the brain often develop learning disabilities from the illness and treatment. When a child comes back to school, he needs a comprehensive assessment for intelligence, achievement, direct observation of his abilities as well as all the reports from the doctor. If his medical condition changes, the child should be at home with a tutor teaching him.

The cancer and treatment may contribute to frequent school absences. If a child can attend school as much as possible, it allows him to have a daily routine, contact with friends, a sense of independence, and hope for the future.

Current practice is to tell the child that he has cancer and have him actively participate in his treatment. Fear of the unknown is usually worse than reality, and a lack of honesty from adults can cause children to feel guilty and isolated. This honesty also extends to the student's classmates. It helps the children to give support to the sick child and to know the facts about cancer.

Many students with cancer will live to adulthood and realize their dreams. In 1993, Melissa, the teen-ager from the beginning of this section gave birth to a healthy baby girl. She shares her thoughts about her life today:

Now it has been three years since my last treatment and I still am frightened sometimes. But usually, I forget about it and I don't feel like I was ever sick. I still get nervous when I have to see my doctor for checkups: what if there's something wrong? But I believe I lived for a special reason. God has a plan for my life. Maybe it was to be a mother. But I am so thankful for the past three years and for my daughter.

Question:
7. There are side effects to chemotherapy because:
(Select the best answer.)
a) it affects the whole body.
b) it is poisonous.
c) it is a rapidly dividing preparation.

Seizure Disorder
Mrs. Anderson is the teacher in Martha's class. Since the beginning of the school year, she has noticed that Martha is sometimes inattentive. Here is an episode of her behavior:

"Martha, Martha!" Mrs. Anderson calls to her as she sits in the front row of class. Martha is staring off into space again. The teacher sighs. Martha seems to be lost in her own world. Sometimes, she just fades out. The girl seems bright, but she does poorly on much of her work. "Martha!" Mrs. Anderson calls again.

Martha blinks her eyes and looks around. "Four?" she answers with a question in her voice, giving the answer to problem seven instead of problem eleven.

What is a Seizure Disorder?
A seizure disorder is caused by temporary neurological abnormalities in the brain that result from unregulated electrical charges. Although we are familiar with convulsive seizures, an individual can also have a seizure that manifests itself as a brief period of unconsciousness or altered behavior.

There are two types of seizures: generalized and partial. Generalized seizures cause a loss of consciousness; the whole body is affected when the electrical discharge crosses the entire brain. There are two types. 1) Tonic-Clonic seizures cause a person to fall, and have a convulsion, which is a sudden, involuntary contraction of groups of muscles. 2) absence seizure, such as Martha's, the person also loses consciousness, but only for a brief time, about 15-30 seconds. The person and those around him may not even realize that a seizure has taken place. Absence seizures can occur up to 100 times per day.

During partial seizures, the electrical discharge is limited to one area of the brain. A temporal lobe or psychomotor seizure causes a person to appear to be in a dreamlike state. The person has no memory of what happened afterward, and makes random movements such as picking at his clothing, repeating a sentence several times, or running away. A focal motor seizure causes a person to have sudden, jerky movements of one part of the body. The person who has a focal, sensory seizure sees things and hears sounds that are not really occurring. Myclonic seizures mostly affect infants and young children and cause them to look startled or in pain during the seizure. Sometimes the children suddenly drop their heads forward and swing their arms upward.

Here are some ways to help a person who is having a seizure:
Complex Partial Seizures - Temporal Lobe and Psychomotor Seizures
During the seizure: The person may have a glassy stare; give no response or inappropriate response when questioned; sit, stand, walk about aimlessly; make lip smacking or chewing motions; fidget with clothing; appear to be drunk or drugged.

Generalized Tonic-Clonic Seizure:
During the seizure: The person may, fall, stiffen, and make jerking movements. Pale or bluish complexion may result from difficult breathing.

After the seizure:

Children may stop having seizures as they approach adulthood. Other people have infrequent seizures that are easily controlled with medication. Some seizure disorders continue and worsen with time. A neurologist can do electroencephalography and magnetic resonance imaging to help find the location of the impulse that causes the seizure. Medications are begun when seizures continue and may cause harm to the person.

Other treatments include surgery. If the single area of the brain can be identified as the cause of the seizures, surgical excision can produce seizure relief. A diet high in fats known as the ketogenic diet can also produce significant improvement.

There is also a device that helps stop seizures called the vagus nerve stimulator. It is an electrode that is surgically placed under the skin of the chest and stimulates the brain through the vagus nerve in the neck. It is effective to stop seizures in one area of the brain and perhaps seizures that come from both sides of the brain simultaneously:
http://www.mayoclinic.org/pediatrics-rst/epilepsy.html

Question:
8. The cause of seizuring is:
(Only one of the following answers is correct.)
a) a brain abnormality.
b) muscles contracting because of stimulation.
c) an uncontrolled electrical discharge in the brain.

Seizure Disorder in School
When working with students who have seizure disorder, it is important to identify any environmental factors that seem to cause a seizure. Extreme stress or fatigue, infectious diseases accompanied by fever may bring a seizure. Bright lights and certain sounds or odors can also bring seizure. If possible, keeping these factors at a minimum helps a child reduce his seizures. Some people experience an aura, an unusual sensation before the seizure begins. Occasionally, people with seizures can learn to distract themselves when the aura occurs and thus avoid the seizure.

Having a seizure in school may result in embarrassment and teasing the sick child. One father describes the effect that seizure disorder had on his son: "When Stephen was 15, we had a consultation with the doctor who said, 'I doubt that the seizures will get better, in fact, I think he will get worse.' I saw a mask fall down over my son's face and I sat and watched him withdraw into himself before my own eyes."

The stigma associated with epilepsy is overpowering for young people who are already trying to grow up and manage their own lives. One way to help classmates is to give them information about seizures, especially the first aid help listed above. If the students know what to do for their classmate, it gives them a sense of control over the situation. They do not need to feel helpless when a seizure happens. As a result, when and if a seizure happens, it is not natural, but students can be supportive of the seizuring classmate.