This column provides a general overview of federal law as it relates to psychiatrists who prescribe psychotropic medication that is administered to children in school settings. Specific situations may require further analysis or consultation with an attorney. Furthermore, state law may impose additional requirements, although state law generally cannot reduce the protections provided by federal law.
Children typically face their highest functional demands, both academic and social, at school. Some of the medications prescribed for them have short half-lives and require administration throughout the day. For example, methylphenidate, a medication effective in treating attention-deficit hyperactivity disorder, is typically administered two or three times daily (1). Accordingly, school personnel become involved in administering medication. Treating psychiatrists should have working knowledge of the regulations that apply, especially if they are to act as advocates for children.
Questions often arise about the role of the school in medication management. Can schools mandate psychotropic medication treatment as a requirement for continued enrollment? Can schools refuse to allow children to attend school during times of specific medication adjustments, such as changing, decreasing, or discontinuing medications? Can schools refuse to dispense medication during school hours? Can schools require parents to sign waivers of liability as a precondition for dispensing medication during school hours?
The relevant federal laws include the Individuals With Disabilities Education Act (IDEA) (2), Section 504 of the Rehabilitation Act (3), and the Americans With Disabilities Act (ADA) (4). IDEA establishes legal parameters for medication administration in school for children who have a disability listed in the act and who, as a result of the disability, receive special educational services. The disabilities specified in IDEA include autism, emotional disturbance, mental retardation, and specific learning disabilities. Also included are physical conditions such as blindness, deafness, hearing impairment, orthopedic impairments, impairments caused by physical disorders (such as cerebral palsy), concomitant impairments (such as mental retardation and blindness), or other health impairments due to acute or chronic health problems, including attention-deficit hyperactivity disorder. IDEA applies to all students in publicly funded schools. Children in private schools are not protected by IDEA.
Section 504 of the Rehabilitation Act and the ADA prohibit discrimination against persons with disabilities in a wide variety of settings, including public as well as some private schools. Section 504 applies to private schools only if they receive federal funds. The ADA applies to all private schools other than those with religious affiliations. Under Section 504 and the ADA, disability has a broader definition than in IDEA and includes physical and mental conditions that cause impairment in major life activities.
These statutes preclude disability-based discrimination and require that reasonable accommodation be made for those with disabilities, whether or not they need special educational services. Mental impairment is defined broadly and can include mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities. Although discrimination is ordinarily thought of as treating two groups of people differently, within limits these statutes also require differential treatment—reasonable accommodations—when special services or support are needed because of a disability.
Can schools mandate that a child receive psychotropic medication as a requirement for continued enrollment? Can schools refuse to allow children to attend school during medication adjustments such as dosage changes or medication discontinuation? Under IDEA, publicly funded special education programs cannot mandate that children receive psychotropic medication as a requirement for enrollment.
Children cannot be denied attendance in appropriate special educational settings during times of specific medication adjustments, such as changing, decreasing, or discontinuing medications. However, the school may seek to change the classroom setting to one deemed more appropriate to the special educational needs of the child. For example, a child with attention-deficit hyperactivity disorder attending a community-based behavioral support class may be recommended for transfer to a more highly structured and supervised special education setting because of symptoms not adequately contained in a less restrictive classroom. Such transfers are subject to the parent's right to challenge the school's proposal and, if necessary, to pursue the matter through an impartial hearing and appeals.
Similarly, under Section 504 and the ADA, schools cannot require that a child receive psychotropic medication, and they must make reasonable accommodations to educate the child.
In a due process hearing under IDEA, the Alabama State Educational Agency reviewed a case in which the Auburn City Board of Education required that an eight-year-old student recommended for special classroom placement also receive methylphenidate (5). The hearing officer from the state agency ruled that it was proper for the school district to provide a special education setting and counseling because the child had an emotional disability. However, parental consent for methylphenidate could not be required as a condition in the child's educational plan. The hearing officer found that he himself did not have the authority to require medication use; such a decision could be made only at the parents' discretion.
Can the schools refuse to dispense medication during school hours? In Cedar Rapids Community School District v. Garret F. (6), the U.S. Supreme Court ruled that a school district had to supply qualified staff to provide medical care for a child whose spinal column was severed at age four. The care included urinary bladder catheterization, tracheostomy care, and ventilator checks. The court ruled that such services were covered under IDEA because they were not diagnostic or evaluative procedures and did not require a physician on-site for implementation. This ruling strongly suggests that administration of clinically necessary medication in the school setting would be covered by IDEA as a necessary related service.
Similarly, if a child with a psychiatric disorder requires psychotropic medication administration during school hours to function within the regular school setting, Section 504 of the Rehabilitation Act and the ADA can be cited to have the school make reasonable accommodations to dispense the medication during school hours. Presumably the school would also be expected to maintain reasonable accessibility of staff to enable the treating psychiatrist to manage mental health treatment.
Can schools require a parental waiver of liability as a precondition for dispensing psychotropic medications during school hours? The Office for Civil Rights of the U.S. Department of Education, which enforces Section 504 and the ADA, issued an administrative ruling in a case presenting this issue (7). The case involved an 11-year-old handicapped child who required medication at school for an allergic condition. The parents complained that Berlinbrothersvalley School District, in Pennsylvania, required a waiver of liability to dispense medication. The Office for Civil Rights ruled that requiring such a wavier violated the IDEA mandate to provide "necessary related services." This ruling supports the position that school districts do not have the discretion to refuse to dispense prescribed medication on the basis of administrative requirements.
Federal laws mandate that schools provide appropriate dispensing of psychotropic medications during school hours. Public schools cannot mandate medication treatment as a condition for enrollment, but they can require special educational services on the basis of a specific disability. Public schools probably cannot require parents to sign a waiver of liability as a precondition for dispensing medication. Treating psychiatrists must form an effective partnership with school staff in order to serve the needs of children with psychiatric conditions.
Dr. Luebbert is associate medical director for child and adolescent services for Community Behavioral Health of the Behavioral Health System of Philadelphia. He is also clinical assistant professor of psychiatry at MCP Hahnemann University in Philadelphia, where Dr. Malone is associate professor of psychiatry and director of child and adolescent psychiatry research. Mr. Rieser is codirector of the Education Law Center in Philadelphia. Send correspondence to Dr. Malone, Department of Psychiatry, Eastern Pennsylvania Psychiatric Institute, 3200 Henry Avenue, Philadelphia, Pennsylvania 19129 (e-mail, firstname.lastname@example.org). George M. Simpson, M.D., is editor of this column.