Pediatric Primary Care Case Studies, 1st Ed.

Chapter 4. A School-Age Child with School Failure Problems

Ann Marie McCarthy

Sharon Yearous

School-age children spend a significant portion of their lives in school; therefore, it is crucial that they be in school, healthy, and ready to learn. When a child is having a problem related to school, families often seek help from their primary care provider. It is important for primary care providers to know how to distinguish physical versus psychosocial etiologies for school absences.

Educational Objectives

1.  Identify the characteristics of school refusal in a school-age child.

2.  Discuss the management of a 12-year-old child with school refusal.

  Case Presentation and Discussion

You have been caring for 12-year-old Katie Murphy since she was 9 months old. Ms. Murphy has brought Katie and her older brother to you for their routine health supervision visits and other minor acute illnesses. To date, Katie has never been diagnosed with any chronic health concerns. Katie’s last examination was for her 10-year-old well child visit. She was healthy and her development was progressing normally.

Ms. Murphy calls the health clinic concerned about Katie and tells the receptionist that Katie has been absent from school sporadically during the last 3 weeks. According to Ms. Murphy, Katie has complained of stomachaches intermittently during that time. Over the last week Katie’s absences from school have increased, all related to the stomachaches. Ms. Murphy states that Katie has not had a fever or any other signs of gastrointestinal distress such as nausea, vomiting, or diarrhea. Her stomachaches occur primarily in the morning and subside later in the day. The receptionist schedules a next day appointment for Katie to be evaluated by you. When you review Katie’s record prior to seeing her, your plan is to evaluate her first for an underlying physical cause for her stomachaches. If there isn’t a physical etiology, you then will evaluate her for school refusal related to a psychosocial problem.

What information do you need to rule out a physical etiology for Katie’s stomachaches? image

When primary care providers see a child or adolescent who has missed a number of days of school, accompanied by a physical complaint, it is important to rule out any potential underlying physical problems. Thus, an assessment of a child with somatic complaints that may be psychosocial in etiology first requires a thorough assessment of potential physical etiologies, including a complete medical history and physical exam. The history plus a physical examination with medical tests, if indicated, should provide the data needed to rule out a physical etiology in children, like Katie, who present with somatic complaints and increasing school absences.

The child’s medical history should involve a prenatal to current age review of body systems, including any associated illnesses, hospitalizations, or surgeries related to a body system, accidents or injuries, current medications (prescription and nonprescription), and any alternative therapies used. Further exploration of any areas that may pertain to presenting health issues should be completed as necessary. In addition, the medical history should include a functional assessment of the child’s self-esteem, nutritional habits, sleep habits, involvement in activities, and screening for any type of abuse. The next step after completing a thorough medical history is to review the family medical and social history. A family medical history includes physical and psychological health concerns such as premature death, heart disease, stroke, diabetes, cancer, mental illness, or other inheritable conditions of siblings, parents, and one prior generation of family members (Jarvis, 2007).

Information on school performance should be routinely obtained on all school-aged children. Primary care providers typically screen children before the age of 5 years for developmental and behavioral problems; however, many healthcare providers no longer do this type of screening once children enter school. Recent recommendations suggest that primary care providers should transition from routine developmental screening to screening school performance for school-age children and adolescents. This approach will help with early identification of problems and interventions to improve the child’s success in school (Kelly & Aylward, 2005). If concerns are identified, contact with school personnel and review of school attendance and achievement records may be warranted (Fremont, 2003). For example, in evaluating school absence, in addition to the documented school absences, discussion with the school nurse may reveal a student who is frequently seen in the school nurse’s office for somatic complaints, essentially being absent from class while still in school.

Psychosocial information should also be obtained to identify behavioral concerns and possible underlying factors contributing to the somatic concern. Screening for emotional problems should be a routine part of all health maintenance visits for children (McCarthy & Eisbach, 2006). An example of a screening instrument that may be appropriate for use in primary care settings is the Pediatric Symptom Checklist (PSC) (Jellinek et al., 1988, 1999). The PSC is one page, with 35 items, completed by parents or children, and designed to help clinicians in outpatient practice screen for school-age children with difficulties in psychosocial functioning. The PSC is included in Bright Futures in Practice: Mental Health and the Bright Futures Web site (http://www.brightfutures.org/mentalhealth/pdf/professionals/ped_

sympton_chklst.pdf
) along with information on reliability and validity, scoring, and cutoff scores for referral.

The final area of history that requires review involves a history of the presenting symptom(s) by starting at the point the symptoms presented until the current time. This review of symptoms can be remembered using the PQRSTU mnemonic (Jarvis, 2007).

•  Provocative or palliative: What brings on symptoms? What makes them better or worse?

•  Quality or quantity: How intense are symptoms? What do the symptoms feel like?

•  Region or radiation: Where do they start? Do the symptoms spread?

•  Severity scale: Use an age-appropriate rating scale and ask what makes symptoms better or worse.

•  Timing: This includes onset, duration, and frequency of symptoms.

•  Understanding: Understand the child’s perception of the problem of concern.

Your review of Katie’s medical history shows that she does not have any chronic conditions and, except for otitis media as a preschooler, she has been seen only for routine preventive health care. As noted earlier, you last saw her for her 10-year-old health maintenance visit, and no physical or psychosocial problems were noted. She lives with her nuclear family—her father, who is an engineer; her stay-at-home mother; and an older brother who is in ninth grade. No other individuals live in the home. There have been no changes in the family health history. Her school screening questionnaire completed by her mother at the 10-year-old health visit indicated that she was receiving A’s and B’s in all subjects and enjoyed school. Her behavioral assessment with the PSC, also completed by her mother, fell within the normal range at that time, although Ms. Murphy reported that sometimes Katie worries, is afraid of new situations, and acts younger than her age.

Katie and her mom are present for the appointment. Katie sits close to her mom and seems distant with a flat affect. Upon questioning the reason for their visit today, initially Katie does not respond, and her mother answers your questions. Katie occasionally offers responses to direct questions but her responses are brief, single-word responses, usually yes or no, and with limited eye contact.

You then ask questions specific to the presenting complaint of stomachaches. Ms. Murphy reports that Katie has missed many days of school over the last 3 weeks due to stomachaches. The stomachaches begin in the morning but often appear to resolve by late afternoon. Katie reports some nausea, but denies vomiting or diarrhea with the stomachaches. Her mother states she has not had any fevers over the last 3 weeks. Katie explains that her appetite is normal, yet her mother interrupts and reports that she does not seem to eat very much. You learn that Katie’s maternal grandmother passed away about 2 months ago from lung cancer but Ms. Murphy says that everyone seems to be coping well. No other recent family stressors were identified.

During the physical examination you ask Katie some more questions. Katie is hesitant to respond but states she started her menses 6 months ago and denies cramps that prevent her from doing her normal activities. Her mother confirms this information. Katie states that she feels tired at times, especially in the morning, but otherwise denies any other symptoms. She describes her stomachaches as hurting all over, but after she’s been up for awhile the pain goes away. She rates her pain as a 4 on a 0–10 pain scale where 0 is no pain and 10 is the worst imaginable pain.

Today’s physical exam reveals no fever, normal heart rate (HR) and blood pressure (BP), height is 59 inches, weight 95 pounds, and BMI 19.2 (64th percentile). Her abdomen is flat and nondistended with bowel sounds present in all quadrants, soft and negative for guarding with light and deep palpation. The remainder of the examination is negative. There are no indications for further lab or diagnostic tests at this time.

Your initial assessment suggests that Katie’s stomachaches are related to a psychosocial concern and her school absence behavior is possibly school refusal. You decide that you need to obtain further information.

What additional questions will you ask Katie and her mother as you consider the possibility of school refusal due to a psychosocial etiology? image

Before answering this question, here is some information about school-age children who miss school that should be considered.

School Absence

Laws mandate school attendance. Children and adolescents are typically absent from school for reasons such as illness, appointments, special family events, religious holidays, or school-sanctioned activities. The National Center for Health Statistics (Bloom & Cohen, 2007) reports that in 2006 approximately 29% of students, 5 to 17 years of age, missed no school in the past year due to illness or injury, 29% missed 1 to 2 days of school, 36% missed 3 to 10 days, and 5% missed 11 or more days.

In addition to school absence due to legitimate reasons, children also miss school for reasons that are not acceptable to school and/or parents or guardians. Children who refuse to attend cause problems for themselves and concerns for parents, guardians, and school personnel. There has been some controversy over how to classify unauthorized school absences. Typically, unauthorized school absences have been categorized into two groups: 1) students who intentionally do not attend school, referred to as truancy; and 2) students who have difficulty attending school associated with emotional distress (King & Bernstein, 2001), usually anxiety or fear, referred to as school avoidance, school refusal, or school phobia (Marcontel-Shattuck & Gregory, 2006). Truancy refers to absence from school that is initiated by the student and is not condoned by school officials, parents, or guardians. Truant students typically are not anxious, but instead, display a lack of interest in school and school rules, antisocial behaviors, and conduct problems (King & Bernstein; Marcontel-Shattuck & Gregory; Sewell, 2008). Students who do not attend school due to emotional distress have been further divided into three main clinical groups: anxious/depressed school refusers, separation-anxious school refusers, and phobic school refusers (Egger, Costello, & Angold, 2003; King & Bernstein). However, not all children who refuse to attend school are truant or anxious (Plante, 2007), and some have mixed school refusal behaviors (Egger et al.).

Kearney and colleagues define school refusal behavior as “child motivated refusal to attend school and/or difficulties remaining in classes for an entire day” (Kearney & Albano, 2004, p. 147). This term thus encompasses all students who refuse to go to school, truants, those with anxiety-related disorders, and other unidentified reasons for school refusal, and does not focus on etiology but instead on behaviors. School refusal behavior occurs in all age groups, in boys and girls equally, and is reported to occur in from 1–5% of students (Fremont, 2003) to as many as 28% of students at some point in their school career (Kearney, 2006). Peak ages appear to be 5–7 and 10–14 years of age (Kearney; King & Bernstein, 2001; Marcontel-Shattuck & Gregory, 2006; Plante, 2007; Sewell, 2008). Transitions and changes from one school to another (Kearney; King & Bernstein) or from an extended time at home and a return to school (e.g., vacations, brief illness) (Marcontel-Shattuck & Gregory), as well as stressful experiences at home (e.g., death of a grandparent or pet) or at school (e.g., a bullying episode or exams), can all be triggers for school refusal behavior (Marcontel-Shattuck & Gregory).

Clinical Presentations

School refusal is complex, with various patterns of physical complaints/ somatization, behaviors, and emotions displayed by children with school refusal behaviors. If a physical complaint is associated with school refusal, complaints may include headaches, abdominal pains, nausea and vomiting, fatigue, and dizziness (Egger et al., 2003; Kearney & Bensaheb, 2006). Both internalizing and externalizing behavior problems are seen in school refusal, such as anxiety, fear, depression, physical complaints, noncompliance, aggression, and temper tantrums. School refusal behavior is not a Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) diagnosis, but is seen as a behavioral symptom in children with a number of DSM-IV-TR diagnoses (Egger et al.). In one study, the most common diagnoses associated with students with school refusal behaviors were separation anxiety disorder (22.4%), generalized anxiety disorder (10.5%), oppositional defiant disorder (8.4%), depression (4.9%), specific phobia (4.2%), social anxiety disorder (3.5%), and conduct disorder (2.8%) (Kearney & Albano, 2004).

Children who are truants do not typically tell their parents that they are missing school. These children often do not report physical complaints but often display more externalizing behaviors such as delinquency, lying, and stealing in addition to not attending school (Fremont, 2003). In contrast, parents of children with anxiety-related school refusal behavior typically know about the absences, and parents are usually concerned about the child’s absences. The child either may completely refuse to attend school or may attend but leave early. These children often report physical complaints and display behaviors related to problems such as fears, anxiety, separation anxiety, social phobia, post-traumatic stress disorder, panic disorders, and depression (Fremont). These behaviors may include crying, panic, temper tantrums, threats of self-harm, and, as noted in Katie’s case, somatization complaints such as stomachaches or headaches (Fremont). Children with anxious school refusal behaviors may have a fear of school that is based in reality (not phobic), such as a fear of being bullied or teased (Egger et al., 2003), an unrecognized learning problem (King & Bernstein, 2001), or a recent life-changing event such as a death in the family or relocation. For many of these children, they feel safer staying at home (Fremont).

Family Dynamics

Dysfunctional family interactions may be noted in children with school refusal behaviors (Fremont, 2003; Marcontel-Shattuck & Gregory, 2006). Family and social stressors such as poverty, unemployment, frequent moves, family conflicts, and a parent with a mental health problem are often found in children with school refusal behaviors (Egger et al., 2003; King & Bernstein, 2001). A study of family functioning in children with school refusal found that single-parent families were overrepresented in this group and that single mothers reported more family problems, particularly role performance and communication (Bernstein & Borchardt, 1996). In a study of 46 adolescents with school refusal behavior and anxiety and major depressive disorders, both parents and children reported low family cohesion or engagement and low adaptability/high rigidity (Bernstein, Warren, Massie, & Thuras, 1999). Parents of children with anxiety-related school refusal have been found to have an increased prevalence of similar symptoms. For example, parents of children with phobic school refusal were found to have an increased prevalence of social phobia, and parents of children with separation anxiety and school refusal have an increased prevalence of panic disorder (Martin, Cabrol, Bouvard, Lepine, & Mouren-Simeoni, 1999).

Consequences

The consequences of school refusal behaviors are both immediate and long term. Immediate consequences are problems with academic achievement, peer relationships, and family functioning. Long-term consequences include ongoing underachievement, employment problems, social difficulties, and an increased risk of psychiatric problems (Fremont, 2003; King & Bernstein, 2001; Sewell, 2008). More negative outcomes are associated with long episodes of school refusal occurring when the student is an adolescent, when the student is depressed, and/or when the student has a lower IQ (Elliot, 1999; Sewell).

You ask Katie and her mother to provide further details about school and the history of absences from school. Katie is in the seventh grade in middle school. Prior to the last 3 weeks, Katie often missed a day or two a month from school for some type of problem that seemed legitimate to mom. During the first week when Katie’s school absences began 3 weeks ago, she was home ill on Monday due to the stomachaches. She returned to school on Tuesday and midway through the morning she called her mother saying that her stomach hurt again. Ms. Murphy picked Katie up from school at 11:15 a.m. Katie went back to school on Wednesday but was reluctant about going and voiced her concerns that she didn’t want to have to leave school with a stomachache again. She was able to attend a full day on Wednesday, but didn’t go to school on Thursday until 10 a.m., and was home on Friday due to stomachaches again. The second week Katie was absent from school on Monday, Thursday, and Friday. Katie’s complaints were the same each day—stomachache and intermittent nausea, no vomiting, diarrhea, or fevers. The third week of absences included full days of being absent from school on Monday, Tuesday, Wednesday, and Friday. In order to recognize patterns of school absence and summarize her school absence, you document it in a calendar format.

This week, the school attendance secretary contacted Ms. Murphy because the school was concerned about Katie’s recent attendance. Ms. Murphy states that she is also concerned about all the days of school that Katie is missing but does not know what she should do. Ms. Murphy is at home with Katie during these days of school absence and enjoys spending the extra time with her. Ms. Murphy acknowledges Katie’s stomachaches and encourages Katie to go to school but she also knows that Katie will most likely report to the school office stating that she doesn’t feel well and they will call and ask Ms. Murphy to pick her up. Katie reports that her stomachaches improve during the day. When asked what she does when she stays home, Katie says she watches TV, plays on the computer, and helps her mother with cooking and chores around the house.

Next, you explain to Katie and Ms. Murphy that you often talk with children alone at this age and following approval from both Ms. Murphy and Katie, Ms. Murphy goes to the waiting room while you interview Katie in private.

An approach for interviewing adolescents is to follow the acronym HEADSS(W), and ask questions about home, education, activities, drug use, sexual behaviors, suicide/depression, and weight (Cohen, Mackenzie, & Yates, 1991; Roye, 1995). Asking questions in this order allows the interviewer to begin with presumably less stressful topics and move to more sensitive areas. You start with general questions about how Katie feels about home and school. Katie denies any problems at home. She gets along well with her parents and brother, although she reports that she sometimes doesn’t want to be around her family. Katie states that she has several friends in school and two best friends that she has known since kindergarten. During the last 3 weeks, her best friends have only called her twice to see why she was not in school. On both occasions Katie told her friends that she just had a stomachache and did not mention anything else. When you ask more about her two best friends, Katie starts to have tears in her eyes and states that she is hurt that they have only contacted her twice in the last 3 weeks. “It’s like they don’t care that I’m not in school,” she says. Katie states she does not participate in any extracurricular activities other than a church youth group. Katie denies any alcohol or other substance use; she reports that she has never tried alcohol or drugs and is not interested in experimenting. She also denies that she is sexually active and reports that no one has ever touched her in a way that has made her uncomfortable.

Making the Diagnosis

Katie’s history and negative physical examination are consistent with school refusal behavior, probably initially related to anxiety and now being reinforced by the response to her staying at home. Having ruled out any physical etiology for Katie’s stomachaches, you determine that Katie’s pattern of school absences appear to be anxiety-related school refusal behavior. This diagnosis needs to be explained to the family, with support provided in helping them understand the connection between mind and body.

You explain to Ms. Murphy and Katie that there does not appear to be a physical cause for Katie’s stomachaches, but people’s emotions, such as anxiety, can result in physical symptoms, such as stomachaches. In addition, the rewards of staying at home and spending time with her mother are now reinforcing Katie’s stomachaches.

Management

What information do you need about the management of school refusal in order to help Katie successfully return to school? image

The first step in developing a management plan for a student with school refusal behavior is to perform a complete assessment of multiple areas including:

•  History of factors that may contribute to, trigger, or maintain school refusal behavior

•  Physical exam to rule out health problems and reassure child and family

•  School information related to achievement, attendance, behavior, and social interactions

•  Behavior screening tools completed by parents and teachers (Sewell, 2008)

In this case, you have carried out a physical exam and obtained background information and a description of the school absence behaviors, but will need more on school performance, social interactions, and psychosocial adjustment in order to develop a comprehensive management plan.

The goal of the management plan for a child with anxiety-related school refusal is to return to school, without unauthorized absences, “happy, healthy, and ready to learn.” This requires a multidisciplinary team approach that will likely include the primary care provider, teachers, school personnel such as the school nurse and the counselor, and the child’s family. The primary care provider rules out organic causes for the physical symptoms and provides information to the team about the link between stress and physiological symptoms; school personnel work with the family on making up missed class work and developing a plan for the child to return to school; and mental health providers may be needed to provide support to manage the school refusal behavior and to help the child and family cope with anxiety and related concerns. The plan needs to be well coordinated, agreed on by all members including the child, and supportive of the family.

The primary care provider needs the parent’s permission to contact the school and to obtain information about school performance. Information to obtain includes course grades; standardized test scores; school attendance history; frequency and reasons for visiting the school nurse; any disciplinary actions; Individualized Education Programs (IEPs) or 504 plans, if there are any; and other pertinent records. An IEP or 504 plan would identify any accommodations needed in the school to help the student succeed (U.S. Department of Education, n.d.). The primary care provider may want the principal, teacher, or other school professional to interpret some of these documents. Some of the questions to be answered through school records include whether the student is performing at grade level or as expected and whether any specific learning disorders have been identified.

Both the student’s parents and teachers may be asked to complete instruments that assess behavior and emotional concerns in general and school refusal behavior specifically. Behavioral questionnaires are helpful in assessing a child’s emotional adjustment and overall behavior (Achenbach & Ruffle, 2000; Glascoe, 2000; Perrin & Stancin, 2002). These instruments often are available in several versions that allow the child, a parent, and/or a teacher to complete similar versions of the instrument and for responses to be compared. As noted earlier, an example of a screening instrument that may be appropriate for use in primary care is the Pediatric Symptom Checklist (PSC) (Jellinek et al., 1988), which has both parent and child versions available. However, when diagnosis is the goal, behavioral assessment instruments, such as the Child Behavior Checklist (CBCL) (Achenbach & Ruffle, 2000) and more specific instruments such as the Children’s Depression Inventory (Kovacs, 2003), may be used. For students with school refusal behavior, the use of an assessment instrument (such as the School Refusal Assessment Scale) that specifically evaluates school refusal behavior and clarifies the motivation for the behavior would be particularly valuable.

School Refusal Assessment Scale (SRAS)

Kearney and colleagues developed a model of school refusal behavior based on what motivates the child to avoid school; such motivators are what reinforce the child’s behavior (Kearney & Albano, 2004). Four reasons are identified, two based on negative reinforcement (avoid or escape anxiety-provoking situations) and two based on positive reinforcement (gaining pleasurable activities or rewards). Table 4-1summarizes these four motivating situations for school refusal behavior (Plante, 2007). In general, children with separation anxiety are motivated primarily by positive reinforcement such as attention from a parent; children with anxiety issues of various types are motivated by negative reinforcement such as escape from school teasing; and children with externalizing behaviors, who are often truants, are motivated by positive reinforcements such as obtaining drugs or video time (Kearney & Albano). There is often an overlap across the functions. A child may start with anxiety/negative reinforcement from being able to escape from school problems, but then as they stay home, also may begin to have positive reinforcers such as television or computer time that also maintain the school refusal behaviors.

Based on this model of what motivates school refusal behavior, Kearney and colleagues developed the School Refusal Assessment Scale (SRAS) (Kearney, 2002, 2006, 2007; Kearney & Albano, 2004). The SRAS measures the four functional areas that are thought to motivate school refusal behavior. There are two versions of the SRAS, one for children (SRAS-C) and one for parents (SRAS-P). Each version has 24 items on Likert scales, scored from 0 (never) to 6 (always). The highest scoring functional area is most likely the main reason for the school refusal behavior. The scales and further information can be found on the Internet.

Table 4–1 Motivations for Avoiding School

Maintained by Negative Reinforcement

Maintained by Positive Reinforcement

To avoid school-based stimuli that trigger anxiety, depression, or both (e.g., teachers, peers, bus, cafeteria)

To pursue increased time and attention from significant others

To escape aversive social or evaluative situations (e.g., anxiety associated with socializing with peers or taking tests)

To pursue tangible reinforcers associated with missing school (e.g., sleeping late, increased TV and video game time, delinquent behavior or substance abuse)

Source: Adapted from Kearney (2002), Kearney (2007), Kearney & Albano (2004), and Plante (2007).

Once information on the child’s school performance and behavioral concerns are obtained, in addition to the physical examination and medical history information, and the function of the school refusal behavior is identified, you can then develop an appropriate intervention strategy. This will require a team meeting of key individuals, including the family, school personnel, school nurse, mental health personnel, and primary care provider. The meeting may take place at the school and is an opportunity for the primary care provider to experience the child’s school environment and have direct interaction with school staff.

In Katie’s case, school attendance records verify that despite her recent increase in absences, her grades have not changed, and she visited the school nurse on the days she was in school with the primary complaint being nonspecific stomachaches. Behavioral assessments were not completed prior to Katie’s appointment with you. Your contact with the school results in an appointment arranged for the next day with Katie, her mother, and the school psychologist. Based on the results of the parent and child versions of the CBCL, and the discussion with the family, the psychologist notes that Katie has increased anxiety but no other identified behavior concerns. Completion of the SRAS reveals that Katie’s school refusal behavior is related to a desire to avoid school due to anxiety from some peer conflicts and, secondary to that, to obtain attention or positive reinforcement from her mother. A team meeting is scheduled for the following Monday to include both her mother and father, you as the primary care provider, the school psychologist, the school nurse, and Katie’s teachers.

Therapeutic plan: What will you do therapeutically? image

As stated earlier, the immediate goal for children and adolescents with school refusal behavior is for the student to return to school (Fremont, 2003). Primary care providers should not provide excuses for school absences unless there is a medical reason for not attending school (Freemont). Treatment will vary based on the age and developmental and emotional needs of the child and the functional analysis of the school refusal behavior. In addition to assisting the child to return to school, the treatment plan may need to include ongoing mental health counseling for the child and/or parents if any family members need treatment for anxiety, depression, phobia, post-traumatic stress disorder, or other mental health concerns. Interventions may concentrate on the child and/or parents and involve school support personnel. The following discussion focuses on approaches for children with anxiety-related school refusal.

The plan to return the child to school often involves systematic desensitization (a gradual return to school) (Fremont, 2003; Kearney, 2006; Plante, 2007). Attending school for part of a day may be less stressful than attending for a full day. It is important that the parents and school personnel be consistent in carrying out the approach of gradual reintroduction. However, if the school refusal episode has not been long, it may be possible to have the student return to school full time immediately (Sewell, 2008).

Cognitive-behavioral approaches may help the child with school refusal behaviors (Fremont, 2003; Kearney & Albano, 2004). Children with anxiety may benefit from relaxation training, both muscle relaxation and controlled breathing. Children with difficulties with peers may benefit from social skills training. Positive reinforcement (e.g., verbal praise, earning time with a valued adult in the school such as a teacher or principal) for school attendance can support the child’s return to school. For older children, contingency management and developing a contract with parents and school personnel can be valuable tools. Older children and adolescents may benefit from understanding the patterns of their own emotional responses and resultant behaviors, such as school avoidance, through the use of diaries, discussions, and counseling. Cognitive restructuring therapy that assists the individual in identifying negative thoughts and modifying these thoughts can be helpful for students with illogical thinking related to their experiences at school. In conjunction with these cognitive-behavioral and counseling approaches, medication for the child’s underlying anxiety or depression problems may need to be considered (Fremont, 2003; Heyne, King, Tonge, & Cooper, 2001; Kearney, 2006).

Parents play a key role in the treatment of school refusal, and must work closely with school personnel to address the student’s school refusal behavior. Behavioral approaches such as systematic desensitization and contingency contracting require intense involvement from parents. Children who require counseling need the support of their parents as they learn how to cope with their anxiety. Parents may need support in recognizing that they are positively reinforcing the child’s school refusal behavior and in addressing their own behavior by learning to provide incentives to the child for coping and disincentives for maintaining the sick role and missing school (Plante, 2007). Parents may need treatment for their own anxiety or other mental health concerns.

School personnel, in partnership with the child’s family and often the child’s primary care provider, will typically develop a detailed management plan for the child’s return to school including how the child’s gradual return to school is to be carried out. For example, will the child take the bus or be brought to school by a parent? Who will meet the child at school? Which classes will the child attend? When will the amount of time at school be increased? Are rewards included for successful attendance? In addition to the management plan, other issues need to be addressed by school personnel. If the child has had an extended episode of school absence, plans for completing missed school work may need to be made. If the motivation for the school refusal behavior was to avoid some aspect of school, such as teasing by other students or learning problems, school personnel need to address these difficulties.

At the team meeting, Katie’s parents learned about Katie’s general anxiety, and Ms. Murphy acknowledged that she now realized that while she enjoyed having Katie at home with her, that this was not in Katie’s best interest. A plan for gradual reintroduction to school was developed, with her attending half days for the next 3 days and then moving to full days the following week. Katie’s homeroom teacher would meet her each morning and provide support as needed. Missed coursework was discussed and a plan to make up missed assignments agreed on. The school psychologist planned to meet with Katie frequently in the next few weeks and to adjust the need for ongoing sessions as appropriate. Sessions with the school psychologist would focus on relaxation techniques and exploring some of the concerns that Katie has related to school, including assistance with peer relationships. Ms. Murphy decided that she would reward Katie with a special activity when Katie had completed a full week of school, and discussed ways to support Katie interacting more with her peers. In consultation with Katie’s parents, you recommend that at this point Katie does not need medication for her anxiety. However, you will reassess this decision at a follow-up visit. The decision was made that Ms. Murphy and the school psychologist will meet with Katie the next morning to discuss the plan. You plan to call the family and meet with Katie after that discussion to see if she will agree to counseling and the plan as arranged.

When do you want to see this patient back again? image

The primary care provider may initiate follow-up with the student’s parent via telephone or written communication within a week to inquire about the effectiveness of the reintroduction plan and with an office visit scheduled in the next few weeks to confirm that the child has returned to school and to follow up on the family’s needs for counseling services. Children who are treated with medications will need to be monitored.

Katie returned for a follow-up visit in one month. She had returned to school, although she still reported stomachaches periodically. Ms. Murphy reported that she did not see any other physical symptoms so encouraged Katie to go to school. She had met with the school psychologist and had learned how to recognize the signs that she was becoming increasingly anxious and how to use some relaxation techniques in response to her anxiety. All of her missed schoolwork had been completed, and her grades seemed to be good. She was interacting more with her close friends, and Ms. Murphy felt that overall Katie seemed happy. Katie spoke more with you and said that she still worried at times, but that school was “OK” and that she was doing more things with her two best friends, including a sleepover planned for the next weekend.

Key Points from the Case

1. School refusal is a common problem that must be addressed immediately using a variety of assessment strategies.

2. School refusal may arise for a variety of reasons; the assessment needs to identify the appropriate causes for the individual child.

3. Management of school refusal requires a team effort, including the child, parents, healthcare provider, and school educators and counselors.

4. The primary care provider needs to be a part of the team, including visiting with the school personnel, attending a team meeting, and following up both with the healthcare and the total management plan to get the child back into school and functioning in a happy and healthy way.

REFERENCES

Achenbach, T. M., & Ruffle, T. M. (2000). The Child Behavior Checklist and related forms for assessing behavior/emotional problems and competencies. Pediatrics in Review, 21, 265–271.

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