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BHIPP Bulletin

Volume 2, Issue 3
September, 2016
Goodbye Summer, Hello School (Refusal)
     After a long hot summer, children in Maryland are now officially back to school. We will devote the next few issues of the BHIPP newsletter to address school-related topics, such as educational services, intellectual and learning disabilities, bullying, and in this issue – school avoidance.

     School refusal among children and adolescents is not uncommon and may present in different ways. Some children may skip certain classes, while others may have lengthy absences or chronic tardiness. Exhibiting problematic behaviors in the morning in an attempt to avoid or miss school, as well as pleading with parents to stay home are also not unusual.

     Children and adolescents may attain positive reinforcement for missing school if they are permitted to engage in activities they enjoy such as sleeping late or watching television while at home. Often, youth are attempting to escape school-based situations that evoke fear or anxiety, such as interacting with others, tests/classwork, transitions between classes, or teachers or peers with whom they have difficulty. If left unaddressed, school refusal may lead to significant short- and long-term consequences including distress, academic decline, isolation from peers, family conflict, and financial difficulties.

     Individual and/or family therapy may be of benefit. Cognitive Behavioral Therapy (CBT), utilizing exposure (gradual practice engaging in the activity that creates anxiety, with relaxation practice) are particularly useful in these cases.

     Additionally, it is important that students, parents, and school staff work closely together to gather and share information, develop a plan for the child to return to school, and identify issues that may be contributing to absences such as comorbid medical problems or familial issues. Families may also consider incentives for school attendance while eliminating positive reinforcement for staying home. Some youth may benefit from a 504 Plan or an IEP (Individualized Education Program) which may allow for the school to put a behavioral plan in place and provide support to the youth while at school. It is very important to get the child back to school as soon as possible; home and hospital is not typically recommended in these situations.

     Some children who present with school avoidance may also meet criteria for an anxiety or depressive disorder, such as Separation Anxiety Disorder, Generalized Anxiety Disorder, Social Anxiety Disorder, or Major Depressive Disorder. In severe cases of anxiety or depression, medication may be helpful. Pediatric primary care providers are encouraged to reassess the patient’s current anxiety and depressive symptoms by using screening tools such as the SCARED and the PHQ-9. Based upon the results of the screening, providers should consider referral for psychotherapy and/or initiating medication depending on the severity of the symptoms and underlying diagnoses. In very severe cases of school avoidance, day hospital treatment may be indicated. If medication is utilized, it is important to treat the underlying anxiety or mood disorder, rather than using PRN medications, which could result in the patient (and the family) becoming dependent on medication exclusively.

     In summary, treatment of school refusal often requires a multi-faceted approach, of which medication is just one component. The combination of therapy, family management techniques, collaboration with school personnel, and medication (as necessary) is most effective for sustained results.

-Dr. Nicole Gloff and Dr. Joyce Harrison, BHIPP Consultants

  • AAP Council on School Health - School Refusal, Phobia, and Avoidance: The Pediatrician’s Dilemma    Link
  • Child Mind Institute - When Kids Refuse to Go to School   Link or PDF
  • Cincinnati Children’s - School Refusal   Link
  • (AAP) - School Avoidance   Link or PDF
  • Screen for Child Anxiety Related Disorders (SCARED) Link
  • Patient Health Questionnaire (PHQ-9)  PDF
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Upcoming Events

Maryland Chapter American Academy of Pediatrics  

Educational Event and Leffler Lecture/Awards Luncheon
September 10, 2016

8:00 am - 2:00 pm
MedChi Building, Baltimore, MD

Maryland Chapter American Academy of Pediatrics 

Developmental Disability Screening Training CME Event
October 29, 2016

9:30 am - 11:00 am 
Leonardtown Library Meeting Room, Leonardtown, MD
Event Flyer & Registration Information

Resources and Information

National Suicide Prevention Week
September 5-11, 2016

For individuals at risk of suicide, behavioral health and primary care settings provide unique opportunities to connect with the health care system and access effective treatment. Almost half (45%) of individuals who die by suicide have visited a primary care provider in the month prior to their death, and 20% have had contact with mental health services.

Below are a number of resources and interventions, some general in scope and others geared towards primary care settings. 

American Foundation for Suicide Prevention

AAP Mental Health Initiatives - Self Harm & Suicide
Includes case vignette and video

AAP News, June 2016
Teen Suicide: a closer look at three key factors

Suicide Safe
SAMHSA's new suicide prevention app helps providers integrate suicide prevention strategies into their practice

The Maryland Department of Health & Mental Hygiene hosts an annual suicide prevention conference. This year's event is Wednesday, October 5, 2016 in Windsor Mill, MD.
Save the Date and Registration Information

BHIPP Bulletin Newsletter Archive

August 2016: College Students and ADHD
July 2016: It's Summertime! ADHD and "Drug Holidays"
June 2016: Understanding Vyvanse
May 2016: Children's Mental Health Awareness Week, May 1-7, 2016
April 2016: "Universal" approaches for child mental health problems
March 2016: Pharmacological interventions for sleep concerns
February 2016: Behavioral interventions for sleep concerns
January 2016: Assessment of sleep disorders
November 2015: 5S's: Key questions for consultation
October 2015: Case discussion regarding school refusal
Copyright © 2016 Maryland Behavioral Health Integration in Pediatric Primary Care (BHIPP), All rights reserved.

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