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Understanding and Managing School Refusal in Children. · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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Music.
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Pediatrics Now is brought to you by the Department of Pediatrics at the University
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of Texas Health Science Center at San Antonio and University Health's new Women's
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and Children's Hospital.
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Today I'm bringing you a talk about school refusal from an expert in pediatric psychiatry.
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This talk is by Dr. Thomas Matthews. He's been a pediatric psychiatrist for more than 20 years.
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He received his medical degree in 1997 from the University of Texas Health Science Center at San Antonio,
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internship in general psychiatry also at the University of Texas Health Science
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Center at San Antonio, as well as his clinical fellowship and residency.
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He's the medical director of Clarity Outpatient Psychiatry.
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Let's listen in. Why learning performance matters. matter.
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With this one, I'm going to kind of jump to number two first,
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and then we'll do kind of one and three.
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Engaged and hands-on learning. The reason I'm going to that one first is because
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we all learn different, right?
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There's people who are visual learners, there's auditory learners,
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there's tactile, and everybody learns a different way.
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So sometimes you've got to find what's the right way.
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If you take somebody who's one kind of a learner and you force them to learn
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the other way, they don't do as well, and then that can trigger anxiety.
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So sometimes the engaged hands-on and learning environment is very good,
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but other times it may not be.
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Social interaction and development, that's another big thing.
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This is something I wanted to bring up here is I like trends.
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I like looking at trends and seeing things.
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So like COVID, for example, pre-COVID, if you ask me, what am I seeing with
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a lot of my kids that come in who have anxiety disorders?
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A lot of times it was either just bullying, generalized anxiety about school
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or related. When COVID hit and everybody kind of things shut down,
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my clinic here had about a two-week lull and that's it before we were up and running.
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What happened is all my kids who were anxious because of bullying,
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that got better. They were home. They were comfortable.
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They were not worried about the school having to go to school.
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After those two weeks of COVID, my kids that needed the socialization and needed
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that interaction, they started having anxiety.
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So my clinic was just as busy with anxiety, but it was a different subset of kids.
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And then when school opened up, that doubled. So I got the anxiety of all of them.
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So this shows that the social interaction is really important with most people
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and the development, but it can also be, you got to remember is that not all
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kids are the same and some need the social interaction and some more introverted
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need a little bit less of it.
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The third one, emotional and behavioral well-being, encouraging structure and routine.
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This makes me think of one of my kids right now who's an inpatient who he's
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homeschooled. And so one of the things I asked him, I always ask my homeschool
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kids, I was like, what are you involved in? Where are you getting your socialization?
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And this kid does a very good job. He's a 15-year-old and he does the school. He goes at self-paced.
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He likes doing that himself and not having to go to the school.
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But what he does is he got himself very involved in Taekwondo.
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And he actually even teaches some of the younger kids with it.
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So for him, he gets his kind of emotional behavior, well-being and interaction
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with other people from another setting.
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So it doesn't always have to be school, but for most kids, school is where they get that.
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And the next, so what is school refusal? So it's a term used to describe the
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signs of anxiety a school-aged kid has in their refusal to go to school.
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So we also call it, you know, school avoidance or school phobia.
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So it could be any of those names that people use.
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Situations. Sometimes you see it with young, young kids when it's the young
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children going to school for the first time.
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But you got to remember, it's also not just the first time, meaning kinder or
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first. It's the first time you do a change.
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So with this, I'm going to talk about my brother and his daughter.
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So my brother is this big, muscular fireman guy.
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And I was texting him yesterday, asking about his daughter's first week of school.
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So she is maybe, her school is a quarter of the mile from my house and she's
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starting sixth grade and it's a new school.
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And so his response when, when I texted him was, she's really enjoying it,
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but she's having that normal sort of school anxiety, you know,
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going there for the first time, which is normal as long as it's not impairing
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your daily function, right?
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Like causing her to get sick or causing whatever. So for her,
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she's having the normal anxiety.
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The funny thing with my brother is I said, Hey, anytime she wants to walk to
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our house after school, she can do that. It's very safe in the neighborhood.
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And my brother My brother basically said, my anxiety won't let me.
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So sometimes I remember in these situations, you've got to remember is it partly
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it could be the kid's anxiety, but sometimes kids are sponges and they absorb our anxiety.
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So sometimes we got to be able to make sure to check ourselves because,
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yeah, my brother has a lot of anxiety about his daughter.
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Even though it's, you know, very safe situation. So the other stuff that situations
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is fear of certain school situations.
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When kids talk about a school refusal, that's not enough for me. You got to dig deeper.
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You got to figure out what it is. And so sometimes if I have kids who are saying
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I'm having trouble at school, I'm like, is it first thing in the morning? Is it before lunch?
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Is it during lunch? Is it after lunch? Or is it before you go home?
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Right. You try to figure it, figure out what the patterns are.
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So with school situations, if kids have a fear, I have to say,
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okay, is it gym class? Is it the cafeteria?
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Is it the hallways between times? Is it a specific class?
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Try to identify where it is because the more we can drill down and figure out
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where it is, the easier it's going to get for us to address that situation or
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wherever the problem is stemming from.
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Now, if you get a kid who has generalized anxiety, their answer could be, it's all day.
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That tells you something too. So you have to sort of say, is this sort of a
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generalized thing or are there specific places?
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Is it just, I don't want to ride the bus, you know? And so then you got to say,
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are they getting bullied? What's going on there?
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So figuring out which situation it is, as opposed to just lumping it into school is very important.
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And then the other is this one, which is the distress over leaving the parent and going to school.
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And as I was saying about the one earlier, even with my brother,
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is that you always have to also look at the parents and don't just ask the kid,
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you know, they have distress over leaving the parent. But sometimes I will say
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to the parent, how are you? How is your anxiety?
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What is it? Because sometimes the parents are subconsciously letting out signals
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that are, I don't want the kid to go because the parents are the ones having a hard time.
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And you got to remember is that whether the kid is anxious or not,
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if you're in an anxious environment, that may trigger anxiety.
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So that's where, where you have to kind of look at all the, all the aspects of it.
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All right, so let's go on to the next slide. So clinical features that we have.
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Usually it's going to be a gradual onset, but a lot of times symptoms may begin
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after absence from school, illness, holiday, weekends.
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The times that I see this the most are the beginning of the school year in August.
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A little bit blurb sometimes after Thanksgiving, but I get a kind of a little
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bit pops in in January after they've had like a two to three week break.
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Break and then also after spring break because sometimes by
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spring break after when coming back to school they're worn
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out they've already had most of the year done they're just kind of
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exhausted they're a little bit checked out so you know usually it could be after
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times like that and if you know you have an anxious kid sometimes you've got
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to prep it it could be something as simple as the kid does great tuesday wednesday
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thursday friday but then on sunday night they start getting their stomach aches
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they start getting headaches they get anxious and it may not just be a bullying.
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It could be sometimes it's just, they're nervous about basically it's anticipatory anxiety.
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They're anticipating the worst. So sometimes by having to address that with
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them can really, really help out.
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Some kids have anxiety approaching school and others refuse to leave the house.
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So with the approaching school, a very good example is, is another kid that
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I have on inpatient, sweetest boy, nine-year-old, his father passed away a year ago.
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And so they brought him in because they're like, he's having school refusal.
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He's having just significant anxiety, crying spells and all this stuff.
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And when I was sitting there chatting with him today,
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I said, well, why? Like, what is it about going to school? And then he said,
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my dad is the one who used to take me to school.
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So every time that somebody takes me to school and I get close,
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I think of my dad and that makes me sad. So I don't want to go.
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So today we were talking about that, about how to say, I said, you know what?
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Every time you're going now, instead of thinking about the sad part,
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think about something silly you did, like your dad's laugh or this.
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And we've got to try to reframe it so that if it is anxiety approaching school
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for him, We're going to change that, put a positive memory instead of a negative.
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If it's one of those where the kid's approaching school and they're anxious
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and there's tons of chaos with kids getting dropped off and everything,
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then you may want to check with the school and say, well, what are other stuff
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we can do about maybe doing early drop off or even coming in five minutes late
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so that you avoid some of that chaos. us.
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Sometimes you can do that to slowly integrate a kid back in.
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Other times once they refuse to leave the house, sometimes that's almost like
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an agoraphobia. That may be just a big fear that they're having or severe generalized anxiety.
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Some of the symptoms that you're going to get, you get somatic symptoms,
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stomachache, headache, and things that improve when staying home.
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So I always ask about the timing. They're saying my stomach hurts.
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I'm like, okay, when does it hurt? How long does it last? Does it last like
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one or two SpongeBob episodes?
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Or when you go home, them what is it how long
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till it gets better you know like is it just
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the car ride if parent has to go pick them up and then it's better when they
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get there so you want to kind of figure out even the timing of that other symptoms
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you get fear panic crying sometimes you get tantrums sometimes you get self-harm
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sometimes i've had kids tell me that they will self-harm because they know that
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will get them home so you want to kind of ask them why and figure out where it's coming from,
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sometimes they may tell you that they're anxious or afraid or they may not want
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to leave the parent because of a change in their life, new school,
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somebody sick in the family, divorce, death, that they're worried that if they leave,
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things may be different when they get home.
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Okay, so then school refusal. So something important to remember is that it's
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not a psychiatric diagnosis.
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If I tried to bill for that with a kid in clinic, that's going to get kicked
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back and I won't get paid for that.
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So you have to remember is that it's not about that word. It's about where is it coming from.
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So for me, I will put school refusal in my notes and make it very clear that
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this is what's happening. But then I have to figure out, is this coming from the anxiety?
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Is this coming from depression? Is it coming from somewhere else?
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Children, anxiety is most common. Adolescents, it's anxiety and mood.
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One of our child psychiatry board questions that we always have is it's the
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number one cause of stomach pain in children and adolescents.
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And the answer we have on that is always anxiety disorders.
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For the most part, that's what causes it. So I, with a lot of kids,
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will talk to them about, I said, if you're nervous, you're increasing your acid
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in your stomach, that could be causing this and that.
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And so I kind of explain it to them, kind of medicalize it a little bit,
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and it helps them understand a little bit.
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And then we can start to address some of the symptoms that are happening.
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They get a lot of somatic complaints, the autonomic stuff, the dizziness,
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palpitations, chest pains, headaches, trembling, diaphoresis.
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I mean, these are all, as you can guess, right, Right. Those are symptoms of
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panic attacks that kids could get, but they may not be able to tell you it's
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a panic attack or whatever.
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They're just having pieces of those symptoms.
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Then with the GI, you get the stomach pain and abdominal pain.
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You get nausea. Some kids even just get vomiting, diarrhea, a lot of different things.
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And then the muscular stuff, people get a lot of back pain and joint pain.
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Sorry, not joint pain, but joint pain. Forgot the T on that one.
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And then let's move on to the next one. So common risk factors.
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So these are just some examples.
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Bullying, school transitions. So the bullying could be if specific kids are
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teasing them, kind of what's happening.
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School transitions could be transitioning from to school or going home for school,
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or it could be just a transition going to the cafeteria, changing classes,
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various things like that.
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In addition to that, classroom changes is also part of that transition.
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Or upcoming presentations or exams. That's a really big one for a lot of people.
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I remember even in med school for me, I'm a pretty chill and laid-back person,
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but I would always get anticipatory anxiety before med school exams.
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I could not eat that morning.
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It's how it was. I actually did that in college before my lacrosse games.
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I just would not do it. As soon as the game starts, I'm completely calm.
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Some people get that upcoming presentation anticipatory stuff,
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so then you want to figure out how to help them with that.
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Other trauma at schools, shootings, assaults, you know, anytime when we hear
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these news stories about, oh, there was a kid that was caught on campus with
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a gun, there are certain kids that then come into us, they're like,
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they have that kind of fear and panic of the unknown. know.
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Other risk factors, new or sick sibling, sick or ill parent,
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family dynamics, as we mentioned earlier too, if somebody had moved or divorced,
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stress, trauma, if there's abuse, whether it's, doesn't have to be happening to them.
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It could be happening to a family member, but they're worried about if I'm not
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there, I'm not able to protect them and stuff.
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And then the last is the world and media stressors. I remember,
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you know, when I was a kid, I'm old.
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So, so, you know, the The TV, you didn't watch it during the day or you couldn't
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have quick access to all this news on your phone, which kids nowadays have.
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So they get information at such a faster rate, but that also can contribute
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to the anxiety because they're getting more information or getting information
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quickly without having maybe all the pieces of the puzzle.
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Okay. So then now let's move on to the, our next slide. Okay.
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Assess what is the primary reason for the school refusal? So it could be multiple
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things. There's escape, there's avoidance, attention rewards.
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So each of these, we'll kind of we'll go into like a little bit escape is if
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there's something, you know, bad going on with them, like let's say it could
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even be bullying or whatever, that they may just want to get out of the situation.
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So, you know, like the kid we were talking about earlier in the football player,
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he may just want to be escaping and not have to
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deal with that he's having a hard time so he just
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doesn't even go into school you get kids who just avoid for for
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various reasons this could also be the bullying it could be just the presentations
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various other stuff attention they they may be like if i'm sick mom stays home
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and pays more attention to me when maybe there's a a new child in the house
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the parents have to deal with the newborn and then when they're sick the parent
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gets to pay them attention.
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So you have to come time, put the whole perspective of the family into the situation
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too. And then last is rewards.
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With rewards for me, the one that I typically think of is if parents are let
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their kids stay home and then when they're home, the kid could be like a weekend
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day where they can just sit and play video games when they're home.
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That's not something you should be doing if you're sick from a school day.
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I'll address that a little bit.
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Later we get into treatment the other stuff is why is behavior continuing is it you know,
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a chronic thing like could be with the bullying if it
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continues and continues if you can't stop it that could be what
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it is if it's because they're getting the reward because the parents not getting
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in discipline if they're at home and they can do whatever they want you know
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you just have to ask yourself why is it continuing and you have to remember
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that sometimes your answer to this maybe i don't know and i tell kids in clinic
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a lot i ask them a question and i'm like i don't know is an an okay answer.
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I don't know means that I need to kind of keep digging and figuring out.
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So if you say, why is the behavior continuing this kid?
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And you're like, I'm not sure. Well, then maybe that means you need to go to
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one of these other things.
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Maybe you need to get more collateral information to records from the school.
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Maybe you need to just kind of observe a little bit more or have a parents kind
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of take more notes or try a rating skills, you know? So there's multiple reasons.
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So you don't have to have an answer for each of these, but each of these are
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a piece of the puzzle that you want to put together to get the picture of what
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is going on with the kid and why are they not wanting to go to school.
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So now we're going to get into the treatment stuff.
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So if you want to progressively increase attendance for kids who are avoided
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or anxiety-based reasons,
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the longer they stay out of school, the worse it can be sometimes getting them
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back in because they get comfortable in certain other ways.
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So one of the things that you try to do is you try to say, let's slowly get it back.
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Have a girl in our partial hospital that I'm taking care of who school started.
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She had so much anxiety before school starting because of fear of bullying and
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various other things. She was inpatient with us for a few days.
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We discharged her, but instead of having her go right back to school,
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we had to go to our partial program, which is our day hospital where you come
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from 830 to like 330 every day.
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So for her, what we're doing is she's coming here. There's no bullying. It's therapeutic.
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So this week she's like, I feel comfortable. People are being nice to me.
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So So we're trying to slowly get her back into this.
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And then what we'll probably do next week is we'll transition.
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We'll try to do, you know, come here for a day and then go to school for a day
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and then try to come back here for a day and then probably get her back in school to address it.
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So you want to progressively increase the attendance. It can be alternating days.
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It can be a couple hours at a time.
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Sometimes with parents, the kids get really nervous. If you have them home,
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you're like, well, hey, you don't have to go today, but we're still going to
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drive up there and we're going to sit in the parking lot for 20 minutes.
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Even though you don't have to go let's just get comfortable with
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it sometimes you have to slowly integrate the kids back into this
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for the reward-based reason so these are the kids who you've got who are like
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i'm sitting home i'm going to be defiant i'm going to play video games then
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you're like no no no that that's you shouldn't do you go straight back to class
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and then if you choose not to go to school then there's going to be sort of
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a consequence because you're staying Staying home for the reward.
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But, you know, there should be, you need to be there.
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And then we got a few more. I'll address a few more.
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Treatment options for that minute. So Dr. Mathis, nurse practitioner Ray has a question in the chat.
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She says, would you ever recommend homebound for these kids?
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And earlier you mentioned reframing. Are there any tips when it's difficult
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for the child to utilize that technique?
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So homebound, so homebound, and this is, and somebody else had asked a question,
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sent us a question pre about this, about, about having a kid in homebound and
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they're having a lot of of anxiety in the school.
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I think, I think homebound for what it was created for homebound is a wonderful thing for some kids.
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The problem with homebound is a lot of times kids get too comfortable and people
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just let them do six months or a year of homebound.
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That's not how it should be. Homebound should be more of a temporary thing that
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if the kid is having such severe anxiety that they are having panic attacks
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and they can't go to school, then yeah, put them in homebound.
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But when they say how long I tell a kid, I said, I may say, Hey,
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let's do two to three months of homebound, but I don't want it to go that long.
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I want to try to get you better quicker. So what you want to do is it,
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if you put them in homebound, then I want to address what is the reason why
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they're having the school refusal.
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If it's panic attacks and anxiety that they're having, you know,
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give me a couple of weeks and let me get those better.
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And then we will slowly try to integrate them into school. So I think,
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I think homebound is a very good thing, but it also can't be an indefinite thing.
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It needs to be, you try to make it time limited.
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And then if you have to extend it a little bit longer, that's okay,
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but it can't be just indefinite because kids become very common.
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So hopefully that answers your question.
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If not asked again, and Millie, you just let me know when stuff comes up.
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Cause I haven't been glancing at the chat. So.
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Okay. Treatment, multifactorial. So basically, if there's psychiatric issues,
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we need to address it. You let us know.
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If there's family issues, address that. If there's a death in the family,
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divorce or anything like that. If there's school issues, get school involved.
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Let them address it. What other factors are involved? both.
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I have had kids who have stomach pain and honestly, they're having stomach pain
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because they're having stomach issues.
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And that's not because of the anxiety, but the stomach problems trigger the anxiety.
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So this is a two-part approach where I'm like, get some of that,
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see a pediatrician, get that stuff figured out first, and then I can address mine.
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So you got to sometimes figure out which is the one we want to use as a primary.
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So look at all the different factors.
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Therapy, very helpful. Anxiety, CBT is really good. Cognitive behavioral treatment,
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very good for anxiety disorders.
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So if the kids are sort of cognitively able to do it, CBT is wonderful.
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The other thing is family therapy, because there's a lot of times,
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remember that, you know, even with my wife being a pediatrician and me a child
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psychiatrist, people are like, oh, you must know how to raise kids.
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But you know, when you go home and you take take off your your
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doctor hat it you try to be a parent
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sometimes we don't always see what we do so i think everybody can be very helpful
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to discuss to have some family therapy so that the parent in case there's anything
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that they're subconsciously doing that they're not aware of that kind of family
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therapy would be very helpful identifying things it could be little triggers.
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All right. So now more treatments. Okay. So here, things that the PCP and therapists do, right?
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Identify contributing factors from the school, right? Diagnose if you see underlying psychiatric causes.
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Now, you notice I didn't put psychiatric disorders necessarily.
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You need to see if there's psychiatric causes. If you're unsure whether it's
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going to be a psychiatric disorder, send them to us, right? This is what we're here for.
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You know, we've got CPAN. You've got, you know, call us and And we can kind
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of help you talk that through.
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And then if appropriate, use SSRIs or refer for therapy.
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A minute ago when they mentioned the hydroxyzine for that one high school kid,
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the football player, hydroxyzine, I really like hydroxyzine. It helps with anxiety.
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It's funny. One of my friends who's a dermatologist, we were joking one day
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and I was talking about hydroxyzine. He goes, oh, I use that for anti-itch.
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I was like, well, it's got two jobs. It's anti-itch, anti-anxiety.
22:41
When somebody gets anxious, sometimes their eczema flares. And then he goes,
22:44
oh my gosh, you're right. This is how you use that.
22:48
Sometimes hydroxyzine is good for sleep with kids, not because it always makes
22:52
them sleepy, but it takes away some of the anxieties so they can fall asleep naturally.
22:55
So sometimes using meds, whether it's a PRN or a scheduled med like an SSRI,
23:00
if it's more an ongoing thing, those can be very helpful.
23:03
And if you're not sure how to do it, call us. This is why we have CP.
23:08
Partner with the patient, the family for a solution. You say,
23:10
hey, let's come, let's do this together. A lot of times the kids feel like they
23:14
have to solve this on their own or they're too scared to try to figure out a solution.
23:18
You let them know, I'm here with you. We're going to do this together.
23:21
And then no school excuse except for medical reasons.
23:24
So that's one of those where we keep that in a gray area. They're having significant stomach pain.
23:30
Even though it's from anxiety and the fear of school, that could be a reason
23:34
to do it, but you can't do it indefinitely while you're getting them into treatment,
23:38
as long as they're engaged.
23:39
And then sometimes you can do more frequent appointments. It makes them feel a little bit better.
23:44
The family, this is the other thing I was going to talk about with the video.
23:47
Okay, house rules of staying. When my kids were sick, when they were,
23:50
my daughter's 20 and my son's 17, when they were younger and they were sick
23:55
and were going to stay home, I was like, do you get to play video games when you're at school?
23:59
They're like, nope. oh, it's like, so if you're homesick, you're not playing games.
24:02
You're going to be either resting, you're going to be doing,
24:06
you know, you could read a book, you can do various other things.
24:09
But we had to, you know, keep those house rules.
24:13
You know, just like if I didn't go to work one day, I shouldn't be able to sit home and do that stuff.
24:20
Focus on the schoolwork, kind of minimize the attention that they're getting
24:23
with it. You know, don't baby them completely. Make sure that they have what
24:26
they need and that they're okay.
24:27
Right. But you don't want to like, reward them for skipping school.
24:33
Sick rules, fever, significant GI symptoms, otherwise you go to school.
24:38
This makes me think of when my son was little, we had a fun little thing that
24:41
we did that when he played, he played tons of sports, still does.
24:44
And sometimes he'd get hurt and I was coaching him, I'd go out there and I'd
24:47
say, hey, he goes, ask me dad. And I'd say, is it bleeding?
24:51
He'd say, no. I was like, is a bone sticking out? And he'd go,
24:54
no. And I was like, you think you can get back in there?
24:56
And he'd either be like, yes, or sometimes he'd say no. If he said no,
24:59
I trusted him to say, let's go off to the side and let's figure this out.
25:02
Usually he just needed to hear me say that. And then he would jump back in and
25:05
he'd get going. So sometimes you have to have whatever, what are the rules, right?
25:09
Fever and GI symptoms, those are big ones, big, big ones.
25:13
We had one of our patients here one time who was having such bad anxiety stuff
25:17
that when she would try to go to school, it would trigger seizures.
25:22
So that's another one that's a sick rules. If you're having a seizure,
25:24
you don't have to go. So this girl's doing so much better now between getting
25:28
us and neurology together.
25:29
It's been wonderful. She's been attending and loves school. So it's a wonderful thing to see that.
25:34
Okay. So now we have the cases. This is the first one I read earlier.
25:38
If anybody wants to jump on, if they have any thoughts about this, please feel free.
25:44
If you want to unmute, if not, I will just keep on talking with this.
25:48
So, so one of the things is that when you get a head injury is another thing
25:52
you're like kind of what's going on with this boy.
25:55
So because when they're reporting that he hasn't wanted to do anything,
25:58
it sleeps all day and is feeling very overwhelmed.
26:01
So in my head, I think what is a couple of things. One, is it sort of a,
26:05
a, still a problem with the concussion that he's still having some sort of like,
26:08
like head injury versus is it an anxiety versus is this a depression to me?
26:14
This kind of jumps off like, man, there's a depression that's there because
26:18
he's, he's not wanting to do anything.
26:20
So having some anhedonia, he's sleeping all day.
26:23
He just kind of aimlessly wanders around, but doesn't go in.
26:27
So I would be like, Like, what is going on with this kid? So sometimes this
26:30
may be one of those. He's not in therapy.
26:32
I would like to have a parent's first thing, get him in with a therapist and
26:36
let the therapist, we need eyes on him.
26:38
We need somebody to see him to try to kind of crack the nut and say, what's happening?
26:42
And then if it is that it's a real big depression, then I'd be like, yes, let's treat that.
26:50
So if somebody were to ask me for a letter allowing him to participate in virtual
26:54
school, I don't always have a problem with that as long as they meet certain
27:00
requirements, meaning you have to engage in therapy.
27:02
You have to see a psychiatrist or whatever it is that we need to do.
27:07
You can't just say, sure, I'll give you virtual therapy because you're still
27:11
not addressing the problem.
27:12
Problem this kid could be having a lot of suicidal thoughts he could be having
27:16
you know just severe severe anxiety so i do allow a letter to participate in
27:22
virtual school but it would be,
27:24
with these you know requirements of things that you need to do all right if
27:29
there's no questions on that one i will move on to the next one.
27:34
So this one, nine-year-old girl presents to her PCP for recurrent headaches and stomach aches.
27:39
On interview, it's noted that she hasn't been to a full day of school for the past two weeks.
27:43
Parents have a hard time getting her there, and when she does,
27:46
she goes to the nurse and calls for them to come pick her up.
27:49
Vomits most days before going to school and when at school. What else do you want to know?
27:53
But I'll move on to the second part, and then I'll discuss a little.
27:56
Patient says she doesn't like talking to other kids and stays by herself.
27:59
At home, is talkative with family, but gets quiet when the topic of school is discussed.
28:03
Having trouble playing with other kids and stays close to
28:06
the teacher at recess school performance has declined over
28:09
the past few weeks and when at home she plays appropriately
28:12
with siblings and neighborhood kids so sometimes
28:16
unfortunately we always have to think about the big bads and you would say okay
28:20
is there what happened a couple weeks ago so you want to try to figure out was
28:23
there any trauma was there any abuse or anything going on where that's a little
28:28
less likely is because when she's at home she's playing appropriately and stuff
28:32
like that so you would but hope that maybe that's not the situation,
28:35
but it's still definitely something you always want to sort of think about.
28:38
And then you figure out, you know, if you can't figure out why.
28:43
What happened a couple of weeks ago, sometimes what I want to do is say,
28:47
well, let's get you treated.
28:48
And maybe the answer will present itself down the road.
28:51
Well, let's see, as long as we get you in a safe situation, sometimes helping
28:55
kind of grease those wheels would be something important.
28:59
This is one of those where from what it's saying, she hasn't been to a full
29:02
day in the vomiting. Her anxiety is so severe, she's withdrawn and stays close to the teacher.
29:07
This is a point where this is definitely impairing her daily function.
29:11
This is what I always tell my students and my fellows, my residents,
29:15
is that I say, when it's time to treat a psychiatric condition is when it's
29:19
impairing your daily function.
29:20
This isn't pairing her day. It's pairing the family's day. It's causing trouble for everybody.
29:26
So you want to figure out what's going on. This in a way makes me think of this
29:30
girl that I had a patient.
29:31
Oh my gosh, this was 15, 20 years ago. And she had selective mutism.
29:35
This girl would chat, chat, chat at home. As soon as she walked across the threshold
29:38
of the door, she wouldn't say a word.
29:40
So she, when she came to see me, I think she'd been in school for eight months.
29:45
And the mom was saying that the teacher and the other kids had never heard her
29:50
say a single word in eight months.
29:52
They just adapted to her because she wouldn't talk.
29:54
So a child psychologist friend of mine had this brilliant idea that what she
29:59
did is the kids had show and tell days.
30:01
So she had the girl do a video show and tell of her house where she showed her friends her house.
30:07
And when she played that at show and tell, all the other kids got so excited
30:12
because They heard her voice for the first time and they were like,
30:14
we got to hear your voice. It was so amazing.
30:16
And that actually was one of the things that started to grease the wheel to
30:19
help her be a little more comfortable at school and help the selective mutism.
30:23
Now, on the back end, I'm also helping grease the wheel by using an SSRI to
30:27
kind of get things moving.
30:29
But sometimes you have to get creative like that to help figure things out.
30:34
So this is one of those where with this girl, it sounds like there's a lot of anxiety.
30:37
And so you want to maybe get her in some therapy with some CBT.
30:41
If she's nine, you could do that. You could get the family in there,
30:45
the parents, so that they don't, by trying to make things better,
30:48
sometimes inadvertently make it worse by babying her too much.
30:52
But this is one of those where we'd have to have a combined approach.
30:55
So you get psychiatry, you get primary care, you get therapy, you get school.
31:00
Everybody together comes together. We can get this kid doing so much better.
31:05
All right. If no questions on that one, yes. There's a question in the chat, Dr.
31:09
Matthews. It says, do you use a screening tool to check for PTSD routinely?
31:15
I do not. So as I give a backup thing, I write for our means of certification
31:20
exams for the American Board of Psychiatry.
31:23
I write some of the questions and it's very interesting is that one of the questions
31:26
I was recently writing, we're talking about doing screening tests.
31:29
And I realized is that for us as psychiatrists, like for me,
31:33
I don't do a regular screening exam because so much of my interview is that screen, right?
31:40
That's what I do in my day-to-day things.
31:43
Would I recommend y'all do that? 100%. Yes. You know, like for anxiety,
31:48
you could do like a SCARED or a GAD-7 or a HAM-A.
31:51
You have very quick things that you can quickly do and you can follow it over time.
31:56
We do that sometimes here in my clinic, but it's not my norm because part of
32:00
my standard is asking about trauma and going for things like that.
32:04
If I asked and the person, you know, says no and seems obvious, there's no trauma.
32:09
That's fine. If it seems like there is trauma and they're discussing it, that's fine.
32:13
I will use those for me for my mid ground where I, I'm like,
32:16
you know what? Something just doesn't feel right. It feels off.
32:19
Like, like, yeah, there's a little bit of trauma, but I can't figure it out.
32:22
Sometimes by getting them to put it on paper and they're doing it really helps
32:26
out. So I 100% recommend, yes, using rating scales.
32:30
Definitely do it. They're very, very helpful.
32:33
Okay, so then let's move on to our next one. This is our last case that we have.
32:37
14-year-old boy presents to PCP for excessive school absences over the past
32:42
month. Parents like a school excuse.
32:44
Discussion he had attended regularly, but three weeks ago had a presentation
32:47
in front of the class and felt sick, so he didn't go to school.
32:50
Went to school after that, but would come home sick on days with the class that
32:54
he had to give a presentation.
32:55
Now he hasn't been to school any days in the past week and a half.
32:59
What else would you like to know?
33:00
So for me, what I would want to know there is I want to be like,
33:03
okay, well, what else is going on? Is it just that one class?
33:05
When is the timing of that class? I want more of a pattern other than just.
33:11
Multiple absences. I want to sort of see what their trend is there.
33:14
Or what else is going on with him in his life? Is there other things happening?
33:18
Is it just the anticipatory anxiety of a presentation?
33:22
Or is it something else?
33:24
So with this, the teacher gave him a passing grade for the presentation due
33:28
to the work he did for preparing it, but not for the presentation.
33:31
And that's good that they helped him with that, but that's also not treating that anxiety.
33:37
He now spends all day in bed playing on his phone or his Xbox,
33:40
which y'all heard my thing about that earlier.
33:42
That can't happen. So what you've done is you take a kid who had fear and anxiety
33:46
of a presentation, and now you're giving them rewards for that behavior.
33:52
So you see how it makes it harder for him to go back.
33:55
Now he hasn't been going for a week and a half because it's like,
33:57
well, why go? If I go there, I could have anxiety.
34:00
If I stay home, I won't have any. So there you go.
34:03
So like this, he argues with the parents in the mornings and anytime the topic
34:06
of school comes up. So what this shows you is this shows you that there's been a progression.
34:10
This isn't like just a one thing. This is a one thing that then developed into something else.
34:15
So now how I would have addressed it a month ago when he had the anxiety of
34:19
the presentation is one way, but how you're having to address it now,
34:23
you're going to have to put some rules about the expert, but if you force them
34:26
back and he still has that anxiety, that's a problem too.
34:29
So you see, this is like a two-prong approach that you have to help out.
34:34
He reports no no motivation to attend school anymore, endorses depressive and
34:37
anxieties. So this is one of those where I'd say, well, let's treat that and see where we go.
34:41
Would I give them a huge unending school excuse?
34:46
No, absolutely not. Once again, you got to have the requirements of you need
34:52
to do this, we need to do this, and you need to do this.
34:54
And you got to figure out how to do that.
34:57
So I think that this is one of those where you have to approach two different aspects.
35:03
One, One, which is the anxiety, which started all this off. Two is the reward-based school refusal.
35:11
All right. With that, I'll just do one last little thing on CPAN,
35:14
and then we'll see if we have anything else.
35:17
Hopefully most of y'all are familiar with CPAN. CPAN offers our pediatric providers
35:21
consultations with a child psychiatrist, care-based learning opportunities.
35:25
Usually you can, you know, get one of us, one of my psychiatrists on the phone
35:29
within five minutes. We answer questions.
35:32
It's it's wonderful i get a lot of these repeat callers who you
35:35
know it's just it makes it easy because you're
35:38
gonna say hey i know last time you told me to do this what about this time where
35:41
would you think about adding this and some of the ones that i've talked to
35:44
a lot i love it that they'll call and they'll say you know
35:47
you've already taught me a couple different things this is what i want to do does
35:49
this sound reasonable and i'm like yes that's great you
35:53
know or did you think about this so this is one of those we're all
35:56
in academics we all love to teach so you call us at cpan and
35:59
we love to help you help your kids so and
36:03
then last cpan how does it work in case
36:06
y'all don't know you call the the access network complex
36:09
case you'll get an lpc or behavioral health specialist just so you're aware
36:14
that people who you talk to are trained very well and they know what they're
36:19
doing and sometimes they can even help you out with whether it's resources or
36:23
various other things before even needing to come to a psychiatrist you may not I need us.
36:26
Or they can say, hey, let's get you in with a psychiatrist. Or when do you get a break in your day?
36:32
We're going to have somebody call you back. Because I have people manning our
36:34
phones eight to five, Monday through Friday.
36:37
And then we can also do these one-time direct consultations where if you're
36:40
like, I don't know what to make of this kid, we can have them come in.
36:43
One of our docs will see them and kind of do a psych assessment.
36:46
And then we'll send them back to you with recommendations saying,
36:49
here's what we think is going on and what we would do.
36:52
And then with that, any questions? Now I'm going to try to look at the chat.
36:58
See, I don't know where I am in the chat. All right, Millie,
37:01
you're going to have to help me.
37:02
I don't know what we've addressed and what we haven't. No problem.
37:05
So we have a question from Dr. Flynn. She said, how do you address a mom slash
37:10
parent who is always going to school to pick up the kid whenever they text her
37:13
every day to come get them?
37:16
So let me, I laugh about that, But let me actually back up.
37:20
Sometimes, I've had some times where I'm like, oh, the parents are just enabling this kid.
37:24
But actually, there's been times where I've stopped and I've looked,
37:27
and you know what? It's actually the school's anxiety that's causing the trouble.
37:31
The school sometimes, and even daycares will do this, where they'll be like,
37:35
you have to pick them up, and they force the parent to.
37:38
So that's a barrier right there. But the parents who have their own anxiety
37:42
and they hear, oh, my kid's sick, and they rush and quickly pick them up,
37:46
that's not helping either.
37:48
So sometimes you want to try to get the parent into maybe some family therapy
37:52
to identify strategies to alleviate their anxiety versus get the parent to say
37:57
meet with the school because you want to figure out what's going on.
38:00
Is there a way where the kid can, if they start having anxiety and panic,
38:03
is there a place they can go off to for like 15 minutes? Yes.
38:06
Calm down, regroup, and then reintegrate back into the class,
38:10
as opposed to just saying, done, rip the kid out of school.
38:14
No, no. Sometimes you want to be able to say, here's a safe space. Go to it.
38:18
Once you're collected, then let's reintegrate with the group.
38:21
So one is I bring it up with the parents because a lot of times the parents
38:24
are doing it because that's a knee-jerk reaction of the parent.
38:26
You worry about your kids. You're like, I'm going to go pick them up.
38:31
But then again, also, you want to make sure and address, is it school's anxiety?
38:35
And this, for some reason, makes me think of a random story that I will tell
38:38
you is that my son, when he was at daycare, he was little, was on a bouncy ball,
38:42
fell off and hit his head and split his head open in the back.
38:46
My wife was coming from the hospital, from the ER and happened to have a staple
38:51
kit with her and comes in and was in her pocket.
38:54
She wasn't going to do that. But what happened is then the people were like
38:57
anxiety of the daycare was like, you can't do that here.
39:00
And she's like, oh, wait a minute. No, no, no. I'm not gonna. gonna she's like
39:04
but the anxiety of the school is like we don't know what to
39:06
do so she was able to kind of calm them down say i'm gonna
39:09
take him we're gonna go get him fixed up you know
39:12
go to urgent care but sometimes you have to look at the parents anxiety versus
39:16
the school's anxiety and often it's a combination of the two now my part was
39:20
my question was actually more of because kids all have cell phones now and in
39:25
the day we didn't so they don't go to the nurse they just directly We text your mom come pick me up.
39:30
I mean if that were my kid I'd be like if you're sick you go to the nurse if
39:34
you come home, then they'll call me but,
39:39
Instantly react to mommy once And pick me up mommy and the mommy will like just
39:45
interrupt their school They text them back and then go get them and it's like
39:49
that's kind of ridiculous I.
39:54
Like I've had my kids over the years, they're sick. I'll be, go to the nurse, right?
39:58
And if the nurse calls me, that is something you definitely want to address the parent.
40:02
If the kid texts you, you tell them, you go to the nurse and let the school call you.
40:07
Because the other way, they're not involved.
40:11
Like the school is not involved and you need the school to be involved in this process.
40:15
All right, what else? I'm going to crash your talk here, which was so great.
40:21
Just because I want to make a plug for our tea chat.
40:24
Program. I just want everybody to be aware that within the context of TCHAT, which is our,
40:32
also, you know, like CPAN, TCHAT is our state-funded telepsychiatry service
40:37
that's available to every, practically every youngster in Texas who attends
40:43
a school that is interested in participating.
40:46
A couple of years ago, we launched a specialty service for school refusal.
40:52
I see Jennifer O'Hare is on the call. She's one of our team members.
40:56
Bailey Wong is our other clinician focused in this area.
41:01
And they've gotten so great doing, implementing evidence-based behavioral therapy,
41:11
cognitive behavioral therapy with kids, with families.
41:15
And apropos your question, Dr.
41:20
Flynn and Thomas, your comments is that it's so great that through Teach Out,
41:25
we already have that liaison with the school.
41:28
So it really helps us to be able to coordinate with, you know,
41:33
a guidance counselor, whether it's sort of a gradual re-entry,
41:38
you know, if that's part of the behavioral plan where, for instance, you know, we agree
41:44
that, you know, for starters, we're just going to get to school and you can
41:47
go right to the guidance counselor's office and chill there.
41:52
Or go to this class, but not that one, all in the service of dealing with as
42:00
much anxiety and apprehension as we can,
42:05
as is comfortable at that point in order to progress.
42:08
When I was in private practice as a psychologist, sometimes I would call schools
42:14
and they never heard of me.
42:16
They don't know who I am, and so what's this guy telling us how we should do
42:21
this or that type of accommodation?
42:24
We already have those relationships with the school through T-Chat,
42:28
so it's really been great. The extent you have youngsters who might profit from
42:35
that, please just call our team here, Shannon.
42:38
They'll be able to tell you what
42:41
to tell families in order to make the referral to that service happen.
42:48
And by the way, hardly any kids end up on medication, as it turns out.
42:52
I thought it would be a lot higher, actually, but it's turned out not to be.
42:55
Severe, severe cases. says, Dr. Blader's right.
42:57
It's those really, really high, high anxiety, but most of it,
43:01
you can fix it just with therapy.
43:05
And family peace is so important.
43:09
And that's where I think we really need a skill, someone who's capable of pushing
43:14
the situation so that we don't get too comfortable with the avoidance.
43:19
And the fact of the matter is, I don't know about you, but I I can count on
43:25
one hand how many times I've seen an anxious kid who doesn't have an anxious parent.
43:30
And they're well-meaning people, but seeing their child that distressed does
43:36
trigger guilt, and I'm not sure what to do.
43:39
I don't want to stress them out. They kind of almost over-identify with the kid's issues.
43:46
So, you know, to have, you know, a sensitive but clear therapist about,
43:54
you know, kind of give such a parent that kind of permission structure to,
44:00
you know, set limits around what, you know, and following through with the exposure
44:05
plan turns out to be really helpful.
44:09
And that's a great segue into our next question that we have.
44:12
I'm going to combine these two questions together.
44:14
Any tips for a teen with significant anxiety and depression who is currently
44:19
in homebound classes to return to school?
44:22
Started by having panic attacks every Monday en route to school,
44:26
calling parent almost daily to pick her up secondary to panic attacks.
44:30
School initiated 504 plan to provide safe area for calming. Eventually,
44:35
truancy became an issue and she was placed on a homebound program.
44:39
Our goal is to return to school part-time and then eventually full-time by the end of the year.
44:45
The question that I'm adding on to this is, what is the role of the pediatrician
44:49
in supporting the family with the educational consequences?
44:53
So I think part of that, so the first part is homebound. We already kind of
44:57
mentioned homebound. Y'all heard my thoughts on that earlier.
45:00
If a kid, if it's so bad that they're having panic attacks, then that's one of those, like Dr.
45:07
Blair and I were just mentioned that, you know, a lot of these kids,
45:09
they don't need medications.
45:11
This is one of those that probably does, because if the panic attacks are that
45:15
bad, you still want to get them into therapy, but you also want to get them
45:18
into see psychiatry and homebound definitely needs to be a temporary thing, but you need to.
45:25
Get the symptoms. Like I tell kids sometimes I was like, you know,
45:27
if your symptoms are a 10 out of 10, right. And zero is, you know, no anxiety at all.
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I was like, I, you know, I'm not magical. I can't get you from a 10 to a zero.
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I want to get you down to a four, right. I want to get you so that you're,
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you're, you're less scared, less anxious therapies.
45:43
What's going to take you from that four down to like that, you know,
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one or two kind of to get you, get you better.
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And then at that point, you're going to work on the integration of,
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can you do homebound? What is the school going to allow?
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Because all schools are a little bit different. Like we said,
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you didn't even get T-Chat involved.
45:58
But some schools will let kids
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come in and do a partial day and then only be there for a partial day.
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Others say, no, it's all or nothing. You may have to do alternating days.
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For the pediatrician, in regards to what they can do, as much as possible,
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I mean, they don't need to call the school.
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That's not their job. But it's just a matter of sometimes saying,
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I have resources for you. Here's a tea chat example.
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Here's a, you know, like I'm trying to think of like the Brighton,
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you know, where you can get people who are school advocates and stuff like that.
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Sometimes you can just give them the resources to help, but our job is going
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to be to manage the symptoms if they do need meds or not, but it's also to educate
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the parents a little bit about talk to the school,
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go to them, do this and all that. I don't call the schools myself.
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Dr. Blair, you have anything you want to add to that?
47:16
And sometimes curtailing the panic attacks overall and in helping to promote exposure.
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Even in that situation, if we agree, okay, well, let's take a bit of a timeout,
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take the pressure off and develop a plan for graduated exposure,
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or in this case, trying to move it along.
47:36
For those folks, it's still super important for them to get out of the house
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as much as possible, even if it's not going to school.
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So even going for a walk around the school building or very often it's social
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things that they find distressing or being out in crowd.
47:53
All that, the cornerstone of treatment for these problems is exposure to the
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point that the situations lose their potency to provoke panic.
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The sustained avoidance, that's the recipe for it to get worse.
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It's like an incubator. That's why, Samantha, your question earlier,
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that's why I reacted so strongly to the question, well, is homebound ever a solution?
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And I said, no, no, no, not unless you want it to live in your basement until
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it leaves 40 years old, because it does take it. Yeah, and I tried to avoid
48:36
it in the one I had recently, and mom asked about it. I said, no.
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I said, that's going to be our last, last resort. Absolutely.
48:46
Or if there are issues with a conflict with a particular kid,
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that might have precipitated it until we work around that.
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But once you get, sees, oh, well, you know, this is pretty good.
48:57
This is a pretty cushy life.
48:58
I do a few worksheets that the school sends, and then the rest of the day I'm
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watching TV, playing games. You know, every day is Christmas.
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For me, with Homebound, I just realized this.
49:10
I think the way that I look at Homebound, to me, that's similar to doing cognitive
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behavioral therapy. It's like the CBT.
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It's going to be time-limited. You're going to have certain goals and things you're going to do.
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You heard me say a minute ago, with Homebound, there needs to be requirements
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that people are going to have, and we have to try to achieve these milestones.
49:26
I agree. I don't do homebound lightly at all.
49:29
I have a few kids and it's good for, but I try to avoid homebound if possible,
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try to get them back into the school.
49:37
Millie, any other questions? Yeah. Just one more of you can make it super quick
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since it's our last five minutes.
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Are there any tips when it's difficult for the child to utilize the reframing
49:48
reframing technique for school? Keep trying.
49:52
No, I don't, unfortunately don't have any great tips for that other than keep trying, right?
49:58
If you're, if you're trying and the kid's not able to do it,
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then I think about how can I take attack?
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Like, do I need to step two steps to the left and come from a different aim? Right?
50:09
Just keep, you just got to keep trying. And eventually you can get the kid to
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hopefully help reframe it, but don't spin your tires in mud.
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But if it's not working, go from a different angle.
50:20
So that's not any great magical tips for you, but it's just keep trying.
50:25
Thank you so much to Dr. Matthews and Dr. Blader for providing this great educational talk for us.
50:31
If you have any questions, again, feel free to call us at CPAN 888-901-2726,
50:38
option three and then two.
50:39
We are more than happy to help you with any of your pediatric patients and any
50:44
of the mental health things that they have going on.
50:46
We hope you've enjoyed this episode of Pediatrics Now. Click on the link for
50:50
free credit if you're a practitioner.
50:52
You can also email us with questions or episode ideas.
50:56
That address is pediatricsnow at U-T-H-S-C-S-A dot E-D-U.
51:02
We release a new episode every Friday.
51:05
I'm Holly Wayment. I hope you can join us for our next episode.