School Avoidance: Helping Kids Get Back to the Classroom – PediaCast CME 117
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Show Notes
Description
Dr. Elizabeth Vickery visits the studio as we consider the growing problem of school avoidance. Many factors conspire to keep kids out of the classroom, resulting in students falling behind and leading to family stress and frustration. We explore the causes of school avoidance and provide practical tips for pediatric providers who support these struggling families. We hope you can join us!
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- Listen to the podcast.
- Complete the post-test at Nationwide Children’s CloudCME.
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Topic
School Avoidance
Presenters
Dr Mike Patrick
PediaCast and PediaCast CME
Nationwide Children’s Hospital
Dr Elizabeth Vickery
Pediatric Psychology
Nationwide Children’s Hospital
Learning Objectives
At the end of this activity, participants should be able to:
- Define school avoidance and distinguish it from truancy
- Identify common psychological conditions associated with school avoidance
- Apply a team-based assessment approach to children with school avoidance
- Select evidence-based treatment and relapse-prevention strategies for school avoidance
Links
Center on Positive Behavioral Interventions and Supports
School Absenteeism and School Refusal Behavior in Youth: A Contemporary Review (Clinical Psychology Review)
School Refusal Behavior (National Association of School Nurses – School Nurse)
The Functional Profiles of School Refusal Behavior. Diagnostic Aspects (Behavior Modification)
Forms and Functions of School Refusal Behavior in Youth: An Empirical Analysis of Absenteeism Severity (Journal of Child Psychology and Psychiatry)
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No one in a position to control content has any relationships with ACCME-defined ineligible companies.
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In support of improving patient care, Nationwide Children's Hospital is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the American Nurses Credentialing Center (ANCC), and the Accreditation Council for Pharmacy Education (ACPE), to provide continuing medical education for the healthcare team.
AMA Statement
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Nationwide Children's Hospital has been authorized by the American Academy of Physician Associates (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credits. PAs should only claim credit commensurate with the extent of their participation.
APA Statement
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Episode Transcript
[Dr Mike Patrick]
This episode of PediaCast CME is brought to you by Pediatric Psychology at Nationwide Children's Hospital.
[MUSIC}
[Dr Mike Patrick]
Hello, everyone, and welcome to another episode of PediaCast CME. We are a pediatric podcast for health care providers.
This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It's episode 117.
We're calling this one School Avoidance, Helping Kids Get Back to the Classroom. I want to welcome all of you to the program. We are so happy to have you with us.
School avoidance is a common and growing challenge for kids and families, especially in the post-COVID-19 era. In-person classes add a social component to the school experience, which was less impactful during the pandemic's virtual classrooms. Of course, social interactions are good and healthy for kids, but sometimes they're negative and stressful, and combine that with underlying anxiety disorders, and it becomes understandable why a growing number of kids avoid school.
There are many other reasons for school avoidance, which we will explore. And once school avoidance gets started, it can be difficult to stop the train, right? Missed classes and assignments put a child behind, increasing their stress and making the situation worse.
Families often seek help at their child's medical home, so it is important for pediatric providers to have a working knowledge of school avoidance, including the reasons it occurs and how best to support families who are struggling. In this episode of PediaCast CME, we will define school avoidance and differentiate it from truancy, which is a different problem altogether that we will talk about a little bit. We will also explore the causes of school avoidance and review evidence-based and team-based approaches to treatment and prevention.
Of course, in our usual PediaCast fashion, we have a terrific guest joining us in the studio to discuss the topic, Dr. Elizabeth Vickery. She is a pediatric psychologist at Nationwide Children's Hospital. Don't forget, after listening to this episode, be sure to claim your free Category 1 credit.
Really easy to do. Just head over to the show notes for this episode. Again, it's 117 over at pediacastcme.org.
You'll find a link to the post-test in the show notes. Follow that link to Cloud CME, click on the Materials tab, and take and pass the post-test, and the Category 1 credit is yours. And we offer that credit to many pediatric professionals, including doctors, of course, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists.
And since Nationwide Children's is jointly accredited by all of those organizations, it's likely we offer the credits you need to fulfill your state's continuing medical education requirements. Of course, you'll want to make sure the content of the episode matches your scope of practice. Complete details are available at pediacastcme.org.
Also want to remind you, the information presented in every episode of our podcast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. Also, your use of this audio program is subject to the PediaCast CME Terms of Use Agreement, which you can find at pediacastcme.org.
So, let's take a quick break. We'll get Dr. Elizabeth Vickery settled into the studio, and then we will be back to talk about school avoidance. It's coming up right after this.
[MUSIC]
[Dr Mike Patrick]
Dr. Elizabeth Vickery is a pediatric psychologist with the Mood and Anxiety Program at Nationwide Children's Hospital, and she's an assistant professor of psychiatry and behavioral health at the Ohio State University College of Medicine. She has a passion for supporting students and families affected by a range of mental health concerns. One of these concerns is school avoidance, which quickly becomes academically and socially harmful for the student.
And just as fast, school avoidance becomes frustrating for parents and the school. So, what are parents to do when their child is avoiding school? Well, you are about to find out.
But first, before we dive in, let's offer a warm PediaCast welcome to our guest, Dr. Elizabeth Vickery. Thank you for stopping by the studio today.
[Dr Elizabeth Vickery]
Oh, thank you. I'm happy to be here.
[Dr Mike Patrick]
Yeah, we're really glad to have you here and to talk about this important topic. So how do we define school avoidance?
And why is the definition of that important? Because it's more than just missing school. It's actively avoiding school.
And so why does it become important to distinguish that?
[Dr Elizabeth Vickery]
Absolutely. So, first thing that's really important to know about school avoidance is that it's child-motivated avoidance of school, meaning that the origins of the avoidance are residing in the child and arising from the child's own motivations. It's not a diagnosis per se, but it is a set of behaviors or actions that can look different in each child.
For example, it can be avoidance of an entire school day, just refusal to go. That's pretty easy to identify. Or it can be avoidance of certain classes or time periods throughout the day.
It can even look to a parent like, my child is going to school because they actually leave in the morning, but it turns out that they're hiding throughout the day, even in the library or the counselor's office or the nurse's office. Or it can look like having severe outbursts in the morning before school or in the evening after school or crying and begging not to go and perseverating on thoughts about school and not wanting to attend.
[Dr Mike Patrick]
Yeah, yeah, absolutely. So how common is this problem where kids are actively avoiding going to school? And what sort of trends are we seeing?
[Dr Elizabeth Vickery]
Unfortunately, extremely common and growing more common, especially after COVID. We see about 5% of children and adolescents at any given time meeting criteria for school avoidance. Throughout their lifetimes, up to 28% of all children avoid school significantly at some point in their academic career.
So really, really common. We're also seeing trends of more and more kids asking for what they say are mental health days, which can in some cases be beneficial, in other cases, equal avoidance and kind of signal the start of avoidance. So, it is quite common.
[Dr Mike Patrick]
Yeah. And why do you think since the COVID-19 pandemic that we've seen a lot more of this?
[Dr Elizabeth Vickery]
Well, unfortunately, some of it was endorsed by necessity, by people needing to be out of school, and then resulted in a lot of online schooling, which can actually be a forum for avoidance as well. Kids can avoid when they're online by not turning on their cameras, not attending synchronous learning, things like that. So unfortunately, after everyone was out of school for a long time, it was much, much harder to return for kids with anxiety-motivated school avoidance.
[Dr Mike Patrick]
I would imagine that a lot of parents can actually relate to this a little bit because there are plenty of people who really begrudgingly return to the office and would much rather be continuing to do their work from home. But again, if it's true avoidance, even doing virtual school, it sounds like they're still going to avoid that too.
[Dr Elizabeth Vickery]
Unfortunately, so. And sometimes it's even harder for a parent to detect that.
[Dr Mike Patrick]
So, you mentioned anxiety. Are there other mental health conditions that are commonly associated with school avoidance?
[Dr Elizabeth Vickery]
Yes, absolutely. So general anxiety, that certainly can be condition-associated. Obsessive-compulsive disorder, repetitively doing things that are really avoidance-based.
Selective mutism, meaning having difficulty speaking to people usually outside the home, like teachers or peers. Conditions like panic disorder that are very physically uncomfortable for a child or teen can lead to avoidance. Also, post-traumatic stress disorder, following some type of a trauma can make a child very resistant to returning to the school environment.
Social anxiety, fear of being evaluated, fear of being graded, which of course school is all about. Also, specific phobias. One thing that I really commonly see is a metaphobia or fear of vomit.
That's really, really common and also can trigger avoidance of the school setting, especially after there's been an episode of the child themselves or someone else vomiting in the classroom that can start a cycle of avoidance. So those really specific phobias can be connected as well.
[Dr Mike Patrick]
Yeah, so pretty complex and so many factors that are involved here. Our primary audience for this podcast is pediatric providers. So how can we screen for this during office visits?
If parents, maybe they're embarrassed to bring it up or there's other things on their mind, how can we make sure that kids aren't slipping through the cracks and that we are sort of uncovering this behavior?
[Dr Elizabeth Vickery]
Absolutely. If there has been avoidance over a period of one to two weeks, it's not likely to recover itself. It's not likely to just get better on its own.
In fact, it's likely to get worse. That's in the absence of illness or another obvious reason for the school absence. Certainly, if family functioning is affected by the avoidance, if there's fighting, arguing about going to school, if grades are starting to decline or if academics are being impacted, that's definitely time to intervene.
[Dr Mike Patrick]
And I would imagine academics become impacted pretty quickly because it doesn't take much missing of school to get behind. And then you add that stress to whatever else, anxiety, if there's other things that started the school avoidance and now that I'm academically behind, that just sort of reinforces to continue to avoid so you don't have to deal with the consequences of being behind and needing to catch up. And that's understandable, right?
[Dr Elizabeth Vickery]
A hundred percent. And that can be absolutely a reason for continued avoidance once started. And that's also why it doesn't tend to get better on its own because the reasons for avoidance compile.
People are going to say, where have you been? Why didn't you do your work? Are you skipping school?
Those types of things can certainly create more anxiety and more avoidance.
[Dr Mike Patrick]
So, it's probably a good idea during well checkups to include, I mean, there's so many things that we're asking pediatricians to talk about in the exam room, but this one is pretty important. And just a, hey, how's your school attendance? You know, just a quick question.
If it's great, it's great. And if it's not, then you can start to delve into that a little bit more. So, if you do discover that you have a kiddo in your practice who is avoiding school, what is a good initial assessment to try to dig at the causes and then figure out where to go from there?
[Dr Elizabeth Vickery]
Absolutely. So, it's really a good frame to look at the problem of avoidance, not as why isn't this child coming to school, but how can the environment be modified or changed, at least temporarily, to make it feel safer for the child to come to school? So, what are we actually looking at in terms of how do we need to accommodate?
Are there health issues, number one, that are leading to the avoidance? What types of patterns are seen in the avoidance? Like what type of setting leads to more refusal to go?
Is it occurring mostly at the beginning of the week, mostly at the end of the week, during evaluative periods, like times of testing, things like that? Are there family situations that are contributing to the avoidance? And what are the consequences?
Are parents trying to encourage school attendance or are parents also somehow reinforcing or certainly not addressing the avoidance itself? Those things are all really important to try to answer with the initial assessment. It's also good to get the perspective of lots of people, like the child themselves, the family members, and teachers at school to start to uncover some of the reasons for the avoidance.
[Dr Mike Patrick]
Of course, that's going to be pretty time-consuming for the individual pediatrician as we're trying to see lots and lots of folks, but we also want to get people and our patients and families plugged into the help that they need. Where would be a good place to start once you've uncovered this and you find that a child is avoiding school, they're getting behind academically, the parents are frustrated, they don't know where to turn, where can we find support for these families?
[Dr Elizabeth Vickery]
Contacting the school counselor directly and inquiring about what patterns are being seen at school. If the parent is concerned about avoidance that's actually happening at school, in the case the child is physically going but attendance isn't happening in class, the counselor is typically the person who's knowledgeable about what's actually happening in school. And also has the knowledge of emotional factors that may be contributing.
Are they seeing the child in their office throughout the day? Is the child coming to them complaining about situations that are going on in the classroom? Are there factors that the parent may or may not be aware of?
So that's always a good place for the parent to start. Also knowing whether or not there are physical factors is really important. So obviously the pediatrician starting off with a physical check, are there physical bases for what is going on with this child?
[Dr Mike Patrick]
I would think that this would also be a great reason to have mental health experts available in your practice. A social worker, someone who can contact the school, that's used to doing that, maybe they have a relationship with folks like the school counselor because they've talked to them before about other patients in the practice. Because for the individual pediatrician to contact the school, that can take time that you're now asking people to wait in your waiting room or can extend the day or into the evening hours and then work-life balance becomes an issue.
So, I think just having that resource of a mental health person who's sort of dedicated to take care of these things in the office, that becomes more complicated with billing and all of the finances of it. But for the kids, I think it would be really helpful to have that. And I know that a lot of our clinics here at Nationwide Children's has psychology and social work support in the clinic, but you don't see that as much in individual pediatric practices.
And I think that's something that would be beneficial if we can figure out how to do it efficiently.
[Dr Elizabeth Vickery]
Absolutely. And knowing how to ask the questions is really important. You referenced earlier, it might be a sensitive situation for a parent, you know, to feel like I'm being told I'm not doing the right thing, or I can't get my child to go to school.
But being asked the questions in a really supportive and non-shaming way by someone who's used to hearing about anxiety and emotional reasons for avoidance and also how hard it is for a parent to send a really distressed child off to school, that could be actually a real time saver for a busy pediatrician to be able to hand off to someone who's used to asking those questions.
[Dr Mike Patrick]
Yeah, yeah, absolutely. We talked a little bit about some of the reasons that school avoidance gets started and with anxiety of some sort, whether it's bullying, whether it's a learning disability, you know, there's so many things. What are some of the biggest ones?
And the reason I think this is important is because, you know, we want to screen everybody, hey, you know, how's your school attendance? But are there certain things in the history that we may discover that might want to make us dig a little bit more in asking about school avoidance? So, in other words, some sort of comorbidities that you may hear about that should kind of ring a bell in your head that, oh, I should ask about school avoidance too.
[Dr Elizabeth Vickery]
Yeah, absolutely. So, basically, we find that there are four main sets of reasons or drivers for school avoidance. Two of them are really much more classically about avoiding things that the child or teen doesn't like or are aversive to them.
The other two reasons are more about achieving things that they do like or like more maybe than the school environment. So, first reason or first set of reasons is staying away from things that can be objects or situations, scenarios at school that make the child feel unpleasant physical symptoms or general distress. So, examples could be riding on the school bus.
It makes them feel nauseated. They don't like starting off the day that way. Being in a crowded hallway gives them feelings of being claustrophobic, closed in.
Maybe being on the playground is difficult for that child for various reasons and so on. Could be being in the classroom, in the lunchroom, all those types of things. Some kids are really avoidant even of things that we as adults kind of perceive as fun like assemblies or something like that.
They can be loud and overwhelming. So, that's the first set of reasons is really avoidance of things that that child or teen finds really unpleasant. Second set of scenarios is avoiding evaluative situations or social situations where the person feels evaluated.
So, these situations could be like reading out loud to the class, being asked to give an oral presentation, just simply receiving grades can feel very threatening to some children with a social form of anxiety. Kids with high levels of perfectionism tend to experience this type of anxiety and resulting avoidance. So, that's kind of the second group of reasons.
Then the two that I mentioned that are more about achieving things that tend to be pleasant are getting attention from a parent or someone else at home rather than going to school. So, being able to stay home with a parent, sometimes parents even will take kids to work with them if they don't go to school that day, which equals a lot of attention and a lot of pleasantness for the child sometimes. Finally, the fourth set of reasons can be actually getting tangible rewards that makes home itself more enjoyable or comfortable than going to school.
So, obvious example of this is like, I play video games. I get on Xbox when I don't go to school. I'm on my phone all day or my laptop playing games, things like that.
So, that's sort of the fourth world of reasons. So, these aren't all separate. They can certainly overlap and one child can have more than one set of reasons why they aren't attending school, but it's really important to discern what those are for any given child.
[Dr Mike Patrick]
Yeah, yeah. Now, a word that we've heard before is truancy. Are school avoiders practicing truancy or is that something different?
[Dr Elizabeth Vickery]
So, it is true. Parents do get letters that say your child is truant and it is, you know, certainly those letters are sent to kids who are avoiding school because of emotional reasons, because of anxiety. Truancy, the definition, is the same as skipping school, which means I am purposely not going to school because I don't want to.
I want to do something else more, such as usually it's older children. Usually, it's associated with having a deviant peer group that they're wanting to spend time with rather than going to school. That's kind of the classic truancy.
It's a choice. It's not driven by emotional distress when it is true truancy. Unfortunately, like I mentioned, sometimes parents do get letters from a truancy officer saying your child has missed this number of days.
Those sometimes can be helpful in recognizing that this is really a significant problem, even though the word truancy is not actually applicable and it is kind of scary to parents.
[Dr Mike Patrick]
Yeah, yeah. So, the school avoidance is more driven by anxiety. There's often a fear of going to school.
You can add to the stress of them getting behind academically and all of those things. And truancy is more oppositional, defiant kind of thing. Like, I just don't want to go and I'm not going to go.
Why is it important for us to differentiate between those two in terms of next steps in the management of the problem?
[Dr Elizabeth Vickery]
Yeah. So, truancy would be looked at as really like a behavioral problem. Like, you're doing this thing that we don't want you to do that's wrong.
And we need to stop you from doing that and figure out how. Certainly, school avoidance that's anxiety motivated is not a behavioral problem or an oppositional problem, though a lot of times it's perceived to be one. Unfortunately, responding as if it is a behavioral problem can worsen the anxiety and therefore worsen the avoidance.
Child is more anxious; they dig their heels in more and become even less likely to attend. Yeah.
[Dr Mike Patrick]
So important to understand that it's not like the child necessarily wants to be away from school. It is a consequence of their underlying mental health issue. And hopefully if we can get that under control and get a plan for getting them back into school and catching up and being supported in the school, that's all going to be very important.
How should treatment be tailored to a child's specific avoidance pattern?
[Dr Elizabeth Vickery]
Absolutely. And this is why an assessment is so important to know what the drivers behind the avoidance are. So, examples of tailoring that could be helpful would be offering partial days of re-entry of school at first.
Some kids do really well with attending easier classes first, ones where teachers are maybe more receptive, more kind of understanding and helpful, or classes where the child is academically stronger or has friends. So that can be easier. Some kids, it's easier to get them in for the morning classes and let them have a temporary early release, or the other way around.
Allow them a late in temporarily to build attendance slowly. Temporarily reducing the complications or the evaluations. When a child is trying to reintegrate into school, like temporarily telling them you can do a presentation just one-on-one with a teacher instead of in front of the class or something like that.
A modification to help them cope with a specific anxiety could be helpful. Providing safe spaces at times where a child can go and have a break if they're having, for example, like a panic attack or something like that. They need to access some coping skills at school.
That can be really helpful. Having designated staff at times can also be really helpful. Having a point person, such as the counselor or another staff member that's really close with the child or has a good relationship.
Even to come out to the car in the morning. Hey, how are you? Glad to see you.
Come on in, kind of usher them from the car to the school building. That can be really helpful. So just really getting at what does this child or teen need to lower the anxiety so that they can attend.
[Dr Mike Patrick]
It would seem that as pediatricians and other primary care providers for kids and teenagers, that we could encourage families to really get in touch with all those folks at school because these kids really do need a team around them. The teachers, the counselors, the principal who have probably seen other kids with similar problems because it is common. And so, they may have some helpful ideas like the sorts of things that you've been mentioning that work well in that particular school.
And it may be different from one school to another, depending on the culture of the school and the personalities of all the folks involved. There's not necessarily, I would imagine, a right and wrong way to do this, but it really does have to be tailored. And to some degree, that tailoring needs to take into account sort of the culture of the school and the temperament of everybody involved on the team that's supporting your child.
[Dr Elizabeth Vickery]
Absolutely. And the child's interactions with everyone and their temperament and the environment at the school. Certainly, that's why it's really important to understand for this child what are the drivers of their avoidance.
[Dr Mike Patrick]
And then in terms of management, there is this concept of exposure-based treatment. What exactly is that and how do we accomplish it?
[Dr Elizabeth Vickery]
Yes. So, I love exposures. That is what I do the majority of my day.
So, I can certainly expound and talk about this a lot. So, exposures are really progressive experiences with approaching things that make us anxious. So really, depending on what that thing is, exposures can be really any interaction with that thing.
Typically, what we do when we're developing some prescribed exposures for a child, say for school avoidance, is we will develop what's called a hierarchy of objects, situations, scenarios that that child is made anxious by. And a specific set of experiences that the child could engage in stepwise to increase toleration for those scenarios or experiences. What we're hoping to get out of the exposure, besides increased tolerance for distress, is a learning experience where the child initially believes they can't cope with that situation or, you know, let's say with feeling evaluated at school or feeling criticized.
Child is avoiding because of extreme fear of that scenario. So slowly we introduce the child to being evaluated, being criticized, feeling, you know, possibly that people are making comments about their performance. And over time, the child becomes able to believe that they can cope with those situations of greater and greater difficulty over time.
So really that learning aspect of that, we're much more capable of coping with things than we believe we are. And that usually things don't turn out to be the worst-case scenario that we think they're going to. That's really the heart of exposures.
[Dr Mike Patrick]
And I love that you mentioned that it's incremental. So, we're not exposing someone like the whole thing. Like if you're afraid of heights, first step is probably not to ride the tallest roller coaster in the world.
You might want to work up to that. And so similar here, we want to give kids a chance to be successful, a little exposure to time, kind of like a vaccine, so to speak, and or allergy treatment. We can look at it that way too.
And I think that from some parents' point of view and even from some school folks' point of view, it may seem like we're giving these kids special attention that we're not giving to other kids. What would you say to folks who would say like we're coddling this group of kids? I mean, because you hear that.
[Dr Elizabeth Vickery]
You do. It's true. Well, and I would say, have you ever seen an exposure?
It doesn't look like coddling. It can look very distressing for that child. I would say schools are really used to differentiating learning and experiences for children.
And sometimes children need actually education about how to tolerate difficult emotions. That's really the part of their education that at that moment they need to focus on. And so, while it may be simple for some people to walk into a classroom and cope with all the things that they're being asked to deal with there, for other children, it's very difficult and really the main part of their learning experience in that moment.
So, I would say that for that child, this is what's the important learning and this is where kind of their learning edge is right at that moment.
[Dr Mike Patrick]
And at the end of the day, we want success for the child. We want them to feel like they belong in school, that they're doing well academically. We want to improve their mental health.
And so, if we do look at it as coddling and not as something that you're doing to try to improve their outcome, then it can get kind of frustrating. But we have to keep in mind that we have a goal and a plan, and these are the steps that it takes to get there. Whereas with other kids, they don't need those steps to get to that same goal, that same plan.
[Dr Elizabeth Vickery]
Absolutely. And this is a conversation that I frequently have with parents and educators, is that we all have things that we're anxious about. Typically, as adults, we've figured out ways around those.
But many people, when they sit and really think about it, can identify areas where exposures would actually be helpful for themselves. You know, it could be public speaking. You know, perhaps an adult is avoiding work experiences that involve public speaking because of anxiety.
You know, travel because of fear of airplanes. I a lot of times tell parents this story. I actually had a fear of flying myself and went and took an exposure-based education class at the Columbus Airport, which was led by Children's Hospital, by the way.
And it was exposure-based. We went into the airport. We went onto an airplane.
We went through some coping skills, which I was pretty familiar with already. But just doing the exposures was extremely helpful, and it was something that I needed to do to succeed in my life. So that can be really helpful, having a conversation with even adults in the child's life about how exposures can really benefit all of us.
[Dr Mike Patrick]
Yeah. And I would imagine a lot of parents might not think of this, but if you do think of something that you have anxiety over and that exposure may help you out, that might even be a conversation to have with your kiddo. Like, okay, you're going to work on school, and I'm going to work on X, Y, or Z, and then we'll support each other in that process.
[Dr Elizabeth Vickery]
A hundred percent. I really encourage parents to talk about what makes them anxious with their child and model that positive coping. You know, I made a speech at work today.
I had to stand up in front of everybody and present an idea. I was really nervous. I was anxious.
I did it. And really get that positive feedback from your child and also model bravery. Yeah.
[Dr Mike Patrick]
And a lot of my guests, like, I really don't want to be on a podcast, but I do have something important to say. And they, you know, do self-exposure, and it all works out okay in the end. Exactly.
Exactly. So, once we have the kid back in school, and we have a plan, and we're doing incremental exposure and all of that, how do we prevent backsliding?
[Dr Elizabeth Vickery]
So, it is really, really important to not celebrate and stop exposures. That's a very common reaction of people. Of course, we want to be like, okay, great, my anxiety is gone.
I don't need to do this anymore. So, exposure is kind of a lifestyle, really, that we need to realize we have to adopt ongoing. So even if the child isn't avoiding school anymore, they still need to be working, you know, let's say it's social anxiety, they still need to be working on, hey, I can still go to soccer or go to this anime club or something like that.
Looking at it not like I've achieved attendance, and now it's just time to stop working on all that. So that's really important. Also, maintaining a consistent routine is really important.
So, getting to bed on time, getting up on time. If this avoidance has had to do with trouble getting up in the morning and getting to school, it's really important not to let that sleep schedule fall off during the weekends. So, staying really regular, consistent with all those things does help the attendance to continue.
It's also really important to watch out for certain time periods, like after an illness. Of course, we all get ill, we all miss school because we were vomiting or had a fever or two good reasons for missing. At times when you're returning after an absence, it can be really hard just because there's increased attention, there's been increased time at home, it's just really hard to get back out there.
So that's a time to watch out for backsliding. Certainly, step up that use of a coping plan, back to basics, regular routine, things like that. I tell parents, don't hesitate in the case of resumed avoidance to withhold things that make home extra comfortable, such as, for example, if there's no attendance, maybe withholding the Xbox or the phone or something like that, so they're not at home using those things rather than going to school, just because that makes it really hard to go to school instead.
And also continuing to reward and celebrate attendance even after, maybe it's not a problem anymore, but just continuing to acknowledge the bravery and the good forward progress.
[Dr Mike Patrick]
A particularly difficult time, I would imagine, is after the summer when kids have been having a great time, they are playing their Xbox, maybe more than they ought to, or getting outside and playing and being with their friends, and all of a sudden, we have this structure in school again. And last school year, it was an uncomfortable experience for me. And then we had the summer, and it would seem that the beginning of a new school year might be a time when backsliding could be pretty big.
[Dr Elizabeth Vickery]
Definitely. Also, there are typical increases overall in avoidance at transitional times, like the transition from elementary school to middle school, where it's usually a whole different building, whole different scenarios, bells ringing, different classes, things like that, whole different set of demands. Middle to high school, same thing.
That can be a time that triggers avoidance. The smaller breaks within school, like the winter break or spring break, that can also re-trigger the avoidance behavior. Or like I said before, times around illness or even planned family vacations or something like that, parents can think, oh, we're past all that avoidance, but then they take a trip and the kid gets really used to not being in school anymore, and then it's difficult going back.
So, just be prepared for those situations and kind of ready with all the skills and coping tools that helped in the first place, ready to have those to go.
[Dr Mike Patrick]
And I imagine as pediatric providers, this is an opportunity for us to make a big difference because we could schedule a recheck for kids who have these issues right before school starts. Just to say, hey, what's our plan? Do we have an idea of how we're going to resume once school gets going again and continue the exposure?
And then maybe even a follow-up visits after that, a month to six weeks later, to see how that plan is going. I mean, those would be legitimate visits, I would think.
[Dr Elizabeth Vickery]
Yeah, that's a great idea. And just checking, simply checking in and asking and being able to praise good progress or maybe troubleshoot any difficulties would be a really good idea.
[Dr Mike Patrick]
Well, this has been a fantastic conversation, and we are going to have resources for providers in the show notes. So, folks, if you head over to pediacastcme.org, find this episode, the show notes, and we'll have those links and resources for you. One is the Center on Positive Behavioral Interventions and Supports.
What is that resource?
[Dr Elizabeth Vickery]
That is a great resource for families and schools to actually have tools that may be really practical that people can use toward building that school attendance.
[Dr Mike Patrick]
Yeah, so that's going to be one to share with your families for sure. And again, it's the Center on Positive Behavioral Interventions and Supports, or PBIS, and again, we'll have a link to that in the show notes. And then we do have some academic articles as well on school avoidance.
One is from Clinical Psychology Review. It is School Absenteeism and School Refusal Behavior in Youth, a contemporary review. The National Association of School Nurses, in their journal, School Nurse, has a nice article on school refusal behavior.
Behavior Modification, that's a journal, the functional profiles of school refusal behavior, diagnostic aspects. So, if you really want to dig deeper into this, we do have resources for you. And then one more, the Journal of Child Psychology and Psychiatry have Forms and Functions of School Refusal Behavior in Youth, an empirical analysis of absenteeism severity.
So, lots to dive into, and that makes sense because it is so common. And if you aren't seeing this in your practice, then I don't think you're asking because it is so common that you definitely have families in your practice that are impacted by this. And that goes across all socioeconomic divisions, right?
I mean, this is not just one socioeconomic problem. We see this in families everywhere and of every sort.
[Dr Elizabeth Vickery]
A hundred percent. We absolutely do. One other resource I wanted to mention is the School Avoidance Alliance.
That's at schoolavoidance.org. That is really, really helpful for parents. It actually has a link to a school assessment that could be given by a pediatrician or parent that links to those four factors that I mentioned that typically underlie anxiety-based school avoidance.
[Dr Mike Patrick]
And we'll drop that one in the show notes as well so folks can find it pretty easily. So once again, Dr. Elizabeth Vickery, Pediatric Psychologist at Nationwide Children's Hospital. Thank you so much for stopping by and sharing your wisdom with us all today.
[Dr Elizabeth Vickery]
Great. Thank you so much.
[MUSIC]
[Dr Mike Patrick]
We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast CME a part of it. We really do appreciate your support. Also, thanks again to our guest this week, Dr. Elizabeth Vickery, Pediatric Psychologist at Nationwide Children's Hospital. Don't forget, you can find us wherever podcasts are found. We are in the Apple Podcast app, Spotify, iHeartRadio, Amazon Music, Audible, YouTube, and most other podcast apps for iOS and Android. So, there might be an easier way for you to subscribe and listen compared to however you reached us for this particular episode.
We also have a landing site over at pediacastcme.org. You'll find our entire archive of past programs there. Show notes for each of the episodes, our continuing medical education information, our terms of use agreement, and a handy contact page if you would like to suggest a future topic for the program.
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Really easy to do. Just head over to the show notes for this episode at pediacastcme.org. You'll find a link to the post test in the show notes.
Follow that link to CloudCME, click on the materials tab taken past the post test, and the Category 1 credit is yours. Super easy. And again, we offer that credit to physicians, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists.
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Also available wherever podcasts are found. Just search for PediaCast. And then there is one more podcast that I host because two is not enough.
You gotta have three. And this one is a faculty development podcast from the Center for Faculty Advancement, Mentoring, and Engagement at The Ohio State University College of Medicine. It's called FAMEcast.
So, if you're a teacher in academic medicine or a faculty member really in any of the health sciences, then this is a podcast for you. And you can find FAMEcast at famecast.org and wherever podcasts are found by simply searching for FAMEcast. Thanks again for stopping by.
And until next time, this is Dr. Mike saying stay informed, keep it evidence-based, and take care of those kids. So long, everybody.
[MUSIC]
