Using the System of Care Approach to Distinguish School ... · missing five days of school due to...
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Using the System of Care Approach to Distinguish School Refusal from School Truancy Connie Chang, MD 1 and Aneela Khan MD 2 1 Sydney Kimmel Medical College, Thomas Jefferson University, 2 Drexel University College of Medicine THERE IS NO CONFLICT OF INTEREST. fdfsdfdsf Missed school x 5 days éPanic attacks Initiated Fluoxetine 10 mg CBT concepts éFluoxetine 15 mg + diphenhydramine 50 mg Christmas Break éPanic attacks é Fluoxetine 20 mg é Panic attacks é Fluoxetine 30 mg Missed x2 weeks Talked to school & nurse fluoxetine à sertraline Talked to school éSertraline 50 mg Missed 30 days due to depression/anxiety Talked to school Went to school last 5 days Referred to Family-based therapy November January February April May June LEARNING OBJECTIVES To recognize the importance of taking a system of care approach to determine whether the symptoms of school avoidance are due to mental illness CASE PRESENTATION This is a 12-year-old Caucasian girl, currently in the 7 th grade, who presented to the outpatient clinic with her father for missing five days of school due to anxiety. She was on the Honor Roll and was accepted by her peers. She shared that she started having panic attacks in the 4 th grade when her father underwent open heart surgery. She was previously evaluated last year for missing 30 days of school consecutively. Consequently, she initiated therapy and fluoxetine. Her history was also significant for: a) Her brother missed 2 years of school 2 years ago; and b) her BMI was above 30 (obese). She wanted to lose weight. Additionally, she was sensitive to her dad’s joking/criticism about her weight. She described her anxiety as, “horrible feelings that distracts me from focusing and makes me feel super uncomfortable, scared, and nervous; like my heart feels like it to would pop out of the chest, hands really sweaty.” During periods of anxiety she felt isolated from the rest of the world. She described these moments as she could not talk and felt frozen. She would end up crying at the nurse’s office. These attacks became more frequent and would last for up to 3 to 4 hours. These behaviors resulted in periods of avoiding going to school. DIFFERENTIALS OF SCHOOL AVOIDANCE ASSESSMENT AND PLAN We applied a system of care approach to assess the etiology of the child. A typical panic attack lasts approximately 30 minutes, but the patient’s panic attacks were unusual in that it would last for several hours which caused the nurse to believe that she was feigning her symptoms to avoid class. The provider contacted teachers in order get a clearer picture of her panic attacks. One teacher observed that excessive noise would be a trigger for her and that she does seem to be emotionally upset when her panic attacks occur. Working with the counselor, we were able to successfully maintain her presence in the classroom until she was admitted to a PHP. Although the patient ultimately missed 30 days of school due to anxiety, we were able to get multiple disciplines to work together to help the child to successfully complete 7th grade and avoid truancy court. DISCUSSION Using the system of care approach we found that one of the difficulties was getting her mother involved. Her mother enabled her avoidance behavior by allowing her to play XBOX games, such as Fortnight, play on the computer, and watch television. Additionally, it was also difficult to the get the entire family to come to family therapy sessions. Although we were successfully able to help the patient past 7th grade, it was imperative that the family get family-based services on board to address the dysfunctional family dynamics. 1. Castiglia, P. T. (1993). School phobia/school avoidance. Journal of Pediatric Health Care, 7(5), 229–232. doi: 10.1016/0891- 5245(93)90009-7 2. Elliott, J. G. (1999). Practitioner Review: School Refusal: Issues of Conceptualisation, Assessment, and Treatment. Journal of Child Psychology and Psychiatry, 40(7), 1001–1012. doi: 10.1017/s0021963099004333 3. Kearney, C. A., & Silverman, W. K. (1993). Measuring the Function of School Refusal Behavior: The School Refusal Assessment Scale. Journal of Clinical Child Psychology, 22(1), 85–96. doi: 10.1207/s15374424jccp2201_9 4. Knollmann, M., Knoll, S., Reissner, V., Metzelaars, J., & Hebebrand, J. (2010). School Avoidance From the Point of View of Child and Adolescent Psychiatry. Deutsches Aerzteblatt Online. doi: 10.3238/arztebl.2010.0043 5. Reissner, V., Jost, D., Krahn, U., Knollmann, M., Weschenfelder, A.-K., Neumann, A., … Hebebrand, J. (2015). The Treatment of School Avoidance in Children and Adolescents With Psychiatric Illness. Deutsches Aerzteblatt Online. doi: 10.3238/arztebl.2015.0655 6. Taylor, L., & Adelman, H. S. (1990). School avoidance behavior: Motivational bases and implications for intervention. Child Psychiatry & Human Development, 20(4), 219–233. doi: 10.1007/bf00706015 RESOURCES *Sponsored by the Regional Council Of Eastern Pennsylvania and Southern New Jersey Child and Adolescent Psychiatry PHP x1 month SCHOOL ANXIETY • Fear of exams • School anxiety • Bullying SCHOOL PHOBIA • Fear of separation from parents SCHOOL REFUSAL • Child spend most time at home • Child reports anxiety, shaking, shivering, dizziness, tachycardia, nausea, stomach pain, vomiting, hyperventilation especially in the AM before school TRUANCY • Parents are not aware that child spend most of the time away from family, home, plays truant with others • Child is oppositional, lies, delinquent, have aggressive behaviors, impulsive behaviors, hyperkinetic symptoms MIXED SYMPTOMS • Absence: occasionally, parents are aware, occasionally they are not • Symptoms: externalizing and internalizing symptoms
Transcript of Using the System of Care Approach to Distinguish School ... · missing five days of school due to...
Using the System of Care Approach to Distinguish School Refusal from School Truancy
Connie Chang, MD1 and Aneela Khan MD2
1 Sydney Kimmel Medical College, Thomas Jefferson University, 2Drexel University College of Medicine
THERE IS NO CONFLICT OF
INTEREST.
fdfsdfdsf
Missed school x 5 dayséPanic attacksInitiated Fluoxetine 10 mg
CBT conceptséFluoxetine 15 mg + diphenhydramine 50 mg
Christmas BreakéPanic attacks
é Fluoxetine 20 mgé Panic attacks
é Fluoxetine 30 mgMissed x2 weeks Talked to school & nurse
fluoxetine à sertralineTalked to school
éSertraline 50 mg Missed 30 days due to depression/anxiety
Talked to school Went to school last 5 days Referred to Family-based therapy
November January February April May June
LEARNING OBJECTIVESTo recognize the importance of taking a system of care approach to determine whether the symptoms of school avoidance are due to mental illness
CASE PRESENTATIONThis is a 12-year-old Caucasian girl, currently in the 7th grade, who presented to the outpatient clinic with her father for missing five days of school due to anxiety. She was on the Honor Roll and was accepted by her peers. She shared that she started having panic attacks in the 4th grade when her father underwent open heart surgery. She was previously evaluated last year for missing 30 days of school consecutively. Consequently, she initiated therapy and fluoxetine.
Her history was also significant for: a) Her brother missed 2 years of school 2 years ago; and b) her BMI was above 30 (obese). She wanted to lose weight. Additionally, she was sensitive to her dad’s joking/criticism about her weight.
She described her anxiety as, “horrible feelings that distracts me from focusing and makes me feel super uncomfortable, scared, and nervous; like my heart feels like it to would pop out of the chest, hands really sweaty.” During periods of anxiety she felt isolated from the rest of the world. She described these moments as she could not talk and felt frozen. She would end up crying at the nurse’s office. These attacks became more frequent and would last for up to 3 to 4 hours. These behaviors resulted in periods of avoiding going to school.
DIFFERENTIALS OF SCHOOL AVOIDANCE
ASSESSMENT AND PLAN
We applied a system of care approach to assess the etiology of the child. A typical panic attack lasts approximately 30 minutes, but the patient’s panic attacks were unusual in that it would last for several hours which caused the nurse to believe that she was feigning her symptoms to avoid class. The provider contacted teachers in order get a clearer picture of her panic attacks. One teacher observed that excessive noise would be a trigger for her and that she does seem to be emotionally upset when her panic attacks occur. Working with the counselor, we were able to successfully maintain her presence in the classroom until she was admitted to a PHP. Although the patient ultimately missed 30 days of school due to anxiety, we were able to get multiple disciplines to work together to help the child to successfully complete 7th grade and avoid truancy court.
DISCUSSIONUsing the system of care approach we found that one of the difficulties was getting her mother involved. Her mother enabled her avoidance behavior by allowing her to play XBOX games, such as Fortnight, play on the computer, and watch television. Additionally, it was also difficult to the get the entire family to come to family therapy sessions. Although we were successfully able to help the patient past 7th grade, it was imperative that the family get family-based services on board to address the dysfunctional family dynamics.
1. Castiglia, P. T. (1993). School phobia/school avoidance. Journal of Pediatric Health Care, 7(5), 229–232. doi: 10.1016/0891-5245(93)90009-7
2. Elliott, J. G. (1999). Practitioner Review: School Refusal: Issues of Conceptualisation, Assessment, and Treatment. Journal of Child Psychology and Psychiatry, 40(7), 1001–1012. doi: 10.1017/s0021963099004333
3. Kearney, C. A., & Silverman, W. K. (1993). Measuring the Function of School Refusal Behavior: The School Refusal Assessment Scale. Journal of Clinical Child Psychology, 22(1), 85–96. doi: 10.1207/s15374424jccp2201_9
4. Knollmann, M., Knoll, S., Reissner, V., Metzelaars, J., & Hebebrand, J. (2010). School Avoidance From the Point of View of Child and Adolescent Psychiatry. Deutsches Aerzteblatt Online. doi: 10.3238/arztebl.2010.0043
5. Reissner, V., Jost, D., Krahn, U., Knollmann, M., Weschenfelder, A.-K., Neumann, A., … Hebebrand, J. (2015). The Treatment of School Avoidance in Children and Adolescents With Psychiatric Illness. Deutsches Aerzteblatt Online. doi: 10.3238/arztebl.2015.0655
6. Taylor, L., & Adelman, H. S. (1990). School avoidance behavior: Motivational bases and implications for intervention. Child Psychiatry & Human Development, 20(4), 219–233. doi: 10.1007/bf00706015
RESOURCES
*Sponsored by the Regional Council Of Eastern Pennsylvania and Southern New Jersey Child and Adolescent Psychiatry
PHP x1 month
SCHOOL
ANXIETY
• Fear of exams
• School anxiety
• Bullying
SCHOOL
PHOBIA
• Fear of separation from parents
SCHOOL REFUSAL• Child spend most time
at home
• Child reports anxiety, shaking, shivering, dizziness, tachycardia, nausea, stomach pain, vomiting, hyperventilation especially in the AM before school
TRUANCY• Parents are not aware
that child spend most of the time away from family, home, plays truant with others
• Child is oppositional, lies, delinquent, have aggressive behaviors, impulsive behaviors, hyperkinetic symptoms
MIXED SYMPTOMS
• Absence: occasionally, parents are aware, occasionally they are not
• Symptoms: externalizing and internalizing symptoms
