Truancy, School Refusal and Medical Excuses

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Truancy, School Refusal and Medical Excuses

• Robert Fawcett, M.D., M.S.
• Member, York County Truancy Response Group

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Objectives

• Recognize truancy and its consequences as a
  public health problem
• Understand how physicians can avoid contributing
  to the problem of truancy
• Discuss possible methods of reducing the problem
  of truancy

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Case 1

• Jamal is a 13 year old male who presented to me
  10/07 with fatigue and history of ADD, off meds.
• Patient c/o not being able to arise in the
  morning. Lived with gm, who said that she was
  not able to get him up for school.
• He c/o being tired all day and yet could not get
  to sleep at night until 12 or 1 am.
• Had history of prior abdominal pain, not
  compliant with medical workup.

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Physical Exam

• BP 100/60, Pulse 78 reg, RR 18 reg, Wt. 180 lbs,
  Ht. 64 inches, BMI 30.9
• WDWN male in NAD
• HEENT Mild nasal congestion
• Neck Mild ant. cervical adenopathy, thyroid
  normal
• Chest clear
• Heart S1S2 WNL, no murmurs, RRR
• Abd obese without masses or megaly, BS WNL
• GU refused and thought examiner was pervert
• Extremities WNL

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Neuro/Psych Exam

• GM noted anger management problems.
• Pt had been in counseling previously for anger
  issues and ADD, not being seen now
• Poor eye contact during exam
• Single word answers, volunteered no info
• School was OK
• Other activities Basketball, TV, Video
• No suicidal ideation, hallucinations or delusions
• No other problems identified, neuro normal

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Questions

• Other information you need?
• What is diagnosis?
• What is appropriate treatment now?
• What do you do RE school note?

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Results of Truancy

• In Baltimore 2/3 truant youths tested drug
  positive
• In San Diego, 44 of violent juvenile crime took
  place during school hours
• In Miami, 71 of 13-16 year olds prosecuted for
  crimes were truant
• In York, 95 of juvenile offenders are truant
• In York, 80 of people in prison have been truant
• In York, truancy increases dropout rate and
  welfare dependence by a factor of 2.5
• Each school dropout costs society over 800,000
  during their lifetime

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Correlates with Truancy

• No parentsgtliving with dadgtliving with momgtliving
  with both parents
• Drug use
• Cigarette use
• Unsupervised time
• Less religious activity/education
• Less expectation of graduating high school
• Less expectation of attending college
• Works more than 10 hours per week

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If you are not part of the solution

• We write excuses for times when child was not
  seen
• We write blanket excuses
• Open ended
• OK-ing intermittent absence
• We write excuse for absence without seeing the
  patient

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Child Not Seen
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Inappropriate, Open-ended
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Blanket Coverage
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Not Seen
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Blanket Coverage
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Long Period Excused, Not Seen
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Not Seen, Not Seen
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You Need to Know

• 10-15 of school children are absent daily
• If child or parent is asking for an excuse,
  chances are that the child has a problem
• The longer the absence, the tougher it is to get
  the child back into school
• Providing an excuse may help the child or parent
  avoid the consequences of truancy
• Penalties can be directed at child or parent
• 300 fine and/or educational program
• Current or prospective driving suspension

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You Need to Know

• Certifying a patient for home study actually
  increases costs for the school system
• The student may only get 1-2 hours of supervised
  instruction per week (aside from parental input,
  if any)
• May help avoid confrontation of problem
• This type of home instruction has been shown to
  trend toward superior outcomes compared to
  in-school studies, though that supposes involved
  and interested parents
• When/how to stop home study?

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Truancy and School Refusal
School Refusal Truancy
Criminality 6 50
Mental Health Anxiety disorder, OCD PTSD, depression Conduct disorder, personality disorder
Sex Ratio 11 Boys gtgt Girls
Parents Aware Yes No
School Work Done Not done
Child Activity At home Not at home
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School Refusal Problems
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How to be part of the solution

• Develop and post a policy for excuses informing
  your pts of what to expect from you

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AAP Statement
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How to be part of the solution

• Develop and post a policy for excuses informing
  your pts of what to expect from you
• Do not excuse a child without seeing him/her
• Avoid blanket excuses
• Keep a record of excuses and document as a
  problem
• No stamps on medical excuses
• Communicate concerns to parent, child, school
  nurse, counselor, and police or CYS
• Allow natural consequences

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How to be part of the solution

• Encourage school attendance
• Ask about grades and friends at WCCs
• BE AWARE of the problems of truancy school
  refusal
• Make Dx
• Treat/Refer
• Partner with
• school /or law

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Dx Look for underlying pathology

• Truancy look for conduct disorder
• ODD
• Gang behavior
• Drug/alcohol abuse
• Criminal activity
• School phobia/school refusal
• Depression
• GAD, separation anxiety, social phobia
• Learning disabilities
• Language impairment
• Physical impairment

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Rx for School Refusal Cognitive behavioral
therapy is cornerstone

• CBT effective in waitlist-control studies, but
  only in 50-80 of kids
• In GAD and depression, meds plus CBT beats CBT
  alone
• CBT equal to educational support
• No studies yet of psychodynamic psychotherapy
• Family therapy felt to be beneficialno studies

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Treatment (continued)

• Whatever therapy is chosen must be individualized
  for each patient
• Milder cases more amenable to rapid interventions
  
• More resistant cases require more approximate
  steps
• Therapy will be more successful with buy-in from
  student, parent, teachers, and admin.

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ICD-9 Codes

• 309.21 School Phobia
• V62.1 Academic Problem
• 312.0 Unsocialized disturbance of conduct
• 312.1 Socialized disturbance of conduct

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10 Tips for Parents

• Value education in the home
• No TV on school mornings, no TV in room
• Have child set and use their own alarm
• Choose clothes the night before
• Have schoolwork, lunch ready to go
• Bath or shower in the evening, not in am
• Walk to school or bus stop with a child who is
  punctual
• To bed 10 min. earlier, get up 10 min. earlier
• Bedtime routine with bath, a story--avoid TV
• When child is ready on time, let him or her know
  how much this helps the whole family

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It is time to act.
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Case 1 Continued

• Diagnosed with school refusal and ADD
• Provided Ritalin for ADD with monthly f/u
• Diagnosed with poor sleep hygiene
• Prescribed melatonin
• Prescribed daily exercise
• Recommended removal of TV, computer from bedroom
• Discussed regular wakeup time daily with GM, who
  seemed receptive but doubtful

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Case 1 (continued)

• Obtained social work consult to check with school
  and help with med/insurance issues
• Referred to Meadowlands
• Promised close follow-up
• Provided excuse only for day of visit

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Barry Shapiro, D.O.

• Med School UMDNJ-SOM 1990
• Residency University of Miami
• 5 years with WellSpan Behavioral Health

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Take Homes

• Develop a strict excuse policy and adhere to it
• Ask about school attendance/performance at all
  visits
• Recognize excuse requests as a red flag
• Involve all pertinent parties in intervention
• Child
• Parent
• School counselors and administration
• Teachers
• Mental Health Providers
• Police or judges

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Case 1 Resolution

• I called in late afternoon 3 days laterno answer
• I called in mid-morning 7 days latertalked to
  patient, who had minor scrape with police and
  had been in school only once since visit
• I called social work to find out
  informationchild was known to CYS (for being
  neglected), GM had fine levied, no payment
• Never saw patient again in our office

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Thank you for your attention

• Questions?