School Refusal

What kid doesn’t like a snow day, or a chance to sleep in with a day off from school? For many children, getting to or staying at school all day can be nothing short of catastrophic.  Every morning they are lethargic and unable to get dressed or get going.  They have somatic complaints (headaches, abdominal pains) which can be persistent and severe; sometimes these complaints vary by the day.  Pushing the child along–forcing them to get ready for school–can elicit extremes of emotion, panic attacks, even violence towards property, self, or others.

Many of these children have school refusal.  An exact definition is tricky, but generally it entails severe, hysterical fear, anxiety, or panic regarding school attendance.  This is not truancy, which is more associated with faking illness to be out of school, while engaging in other(frequently anti-social) activities.  There can be some overlap–certainly some kids anxious about school can get into quite a bit of trouble while being absent.  Reports of occurrence vary from 5% to as high as 28%(if we include children who eventually, after great prompting, finally make it).  It peaks in 5-6 and 10-11 year olds.  Likely 25% have an associated psychiatric diagnosis–typically anxiety, depression, or OCD.

There can be many triggers.  Some children are just fearful of public bathrooms.  Sometimes there is justifiable fear for safety–physical safety from bullying or dangerous neighborhoods, or reputation safety from cyber-bullying or public shaming.  It can result from home difficulties–family illness or violence, financial disruption.  Note that children with real chronic medical conditions and legitimate physical complaints can develop school refusal from fears regarding worsening of their condition at school or just because they hate feeling “different.”

School refusal is a difficult problem requiring complex and nuanced management–no “one size fits all.”    Parents should maintain home routines:regular bedtime and wake up.  Homework should be completed; where possible, tests should be taken.  NO screen/phone time for a child while not in school due to anxiety.  Schools need to be flexible: allow the student to gradually increase school time or alternatives to in classroom attendance (any time in the building is positive).  Too severe a reaction–“my way or the highway” by administration is unhelpful.  But so is over-leniency: every complaint should not result in nurse discharging the student for the day.  School must be sensitive to reasonable concerns regarding personal security.  Developing positive reinforcements for attendance–by parents and schools–should be promoted.  Counseling, psychotherapy, and cognitive behavioral therapy can frequently be employed.  In selected situations, judicious use of psychoactive medications may be prescribed.

We should remember that generally these are good kids with a problem that requires our patience, understanding, and support.  Nobody is talking “indulgence” or “molly coddling.” But we must think these things through very carefully before we act.  If you have a child who is experiencing this type of difficulty please give me a call and let’s see what we can do.

Thanks for following.

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Peanut Allergy

Peanut allergy management has made the news again this week.  That is because of the evolving recommendations for how to address the problem, which have essentially “done a 180” and are exactly the opposite of where we were with this topic as recently as just a decade ago.  Then, avoidance was the conventional wisdom.  And I have previously commented on the subject myself.  Note that peanut allergy has been a growing problem in the US, where it has increased from 0.7% to > 2% of children from 1999 to 2010.  While rare, peanut allergy causes by far the most mortality from food caused anaphylaxis.

The change grew out of a surprising observation by doctors in Britain who noted that the incidence of peanut allergy among British Jewish children was much higher than children in Israel.  And it was noted that many Israeli children enjoy a popular peanut based snack called Bamba.  So they studied peanut allergy prone children aged 4-11 months, introducing peanut based foods to half the kids and no early peanut introduction to the rest.  The findings were startling and definitive: peanut allergy developed in only 1.9% of the peanut fed group as opposed to 13.9% of those avoiding peanut.

Hence the new and very different guidelines–instead of avoidance, we now recommend earlier introduction.  For infants from non-allergic families or those kids with mild eczema only, introduce peanut after 6 months as before.  Never give a child under age 4 a whole peanut (or any small, hard food for that matter because of the risk of choking) and peanut based food should not be the first solid introduced.

For children from families with strong history of peanut or egg allergy, or for those kids with moderate to severe eczema, the approach is more involved.  Blood tests and skin testing performed by an allergist or dermatologist, to assess risk beforehand.  Then, for those who are deemed lower risk, introduction of small amounts of peanut food by 4-6 months old, preferably the initial ingestion in the doctor’s office.  This can be 6-7 gm of food divided in 3 meals.  A good way to do it is to mix a few tsp of peanut butter with an equal amount of warm water to make a slushy consistency.  As above, never give a child a whole peanut and the peanut food should not be the first solids introduced.

So after 31 years of clinical practice I’ve seen the recommendations go one way and now the other.  If I keep this up long enough maybe someday we’ll head back in the other direction again. But for now, this is the best available data so this is the way we should be doing it.

Please contact me with any questions or comments, and thanks for following.