Pediatric Primary Care Case Studies (13 page)

Ann Marie McCarthy
Sharon Yearous

School-age children spend a significant portion of their lives in school; therefore, it is crucial that they be in school, healthy, and ready to learn. When a child is having a problem related to school, families often seek help from their primary care provider. It is important for primary care providers to know how to distinguish physical versus psychosocial etiologies for school absences.

Educational Objectives

1.   Identify the characteristics of school refusal in a school-age child.

2.   Discuss the management of a 12-year-old child with school refusal.

   Case Presentation and Discussion

You have been caring for 12-year-old Katie Murphy since she was 9 months old. Ms. Murphy has brought Katie and her older brother to you for their routine health supervision visits and other minor acute illnesses. To date, Katie has never been diagnosed with any chronic health concerns. Katie’s last examination was for her 10-year-old well child visit. She was healthy and her development was progressing normally.

Ms. Murphy calls the health clinic concerned about Katie and tells the receptionist that Katie has been absent from school sporadically during the last 3 weeks. According to Ms. Murphy, Katie has complained of stomachaches intermittently during that time. Over the last week Katie’s absences from school have increased, all related to the stomachaches. Ms. Murphy states that Katie has not had a fever or any other signs of gastrointestinal distress such as nausea, vomiting, or diarrhea. Her stomachaches occur primarily in the morning and subside later in the day. The receptionist schedules a next day appointment for Katie to be evaluated by you. When you review Katie’s record prior to seeing her, your plan is to evaluate her first for an underlying physical cause for her stomachaches. If there isn’t a physical etiology, you then will evaluate her for school refusal related to a psychosocial problem.

What information do you need to rule out a physical etiology for Katie’s stomachaches?

When primary care providers see a child or adolescent who has missed a number of days of school, accompanied by a physical complaint, it is important to rule out any potential underlying physical problems. Thus, an assessment of a child with somatic complaints that may be psychosocial in etiology first requires a thorough assessment of potential physical etiologies, including a complete medical history and physical exam. The history plus a physical examination with medical tests, if indicated, should provide the data needed to rule out a physical etiology in children, like Katie, who present with somatic complaints and increasing school absences.

The child’s medical history should involve a prenatal to current age review of body systems, including any associated illnesses, hospitalizations, or surgeries related to a body system, accidents or injuries, current medications (prescription and nonprescription), and any alternative therapies used. Further exploration of any areas that may pertain to presenting health issues should be completed as necessary. In addition, the medical history should include a functional assessment of the child’s self-esteem, nutritional habits, sleep habits, involvement in activities, and screening for any type of abuse. The next step after completing a thorough medical history is to review the family medical and social history. A family medical history includes physical and psychological health concerns such as premature death, heart disease, stroke, diabetes, cancer, mental illness, or other inheritable conditions of siblings, parents, and one prior generation of family members (Jarvis, 2007).

Information on school performance should be routinely obtained on all school-aged children. Primary care providers typically screen children before the age of 5 years for developmental and behavioral problems; however, many healthcare providers no longer do this type of screening once children enter school. Recent recommendations suggest that primary care providers should transition from routine developmental screening to screening school performance for school-age children and adolescents. This approach will help with early identification of problems and interventions to improve the child’s success in school (Kelly & Aylward, 2005). If concerns are identified, contact with school personnel and review of school attendance and achievement records may be warranted (Fremont, 2003). For example, in evaluating school absence, in addition to the documented school absences, discussion with the school nurse may reveal a student who is frequently seen in the school nurse’s office for somatic complaints, essentially being absent from class while still in school.

Psychosocial information should also be obtained to identify behavioral concerns and possible underlying factors contributing to the somatic concern. Screening for emotional problems should be a routine part of all health maintenance visits for children (McCarthy & Eisbach, 2006). An example of a screening
instrument that may be appropriate for use in primary care settings is the Pediatric Symptom Checklist (PSC) (Jellinek et al., 1988, 1999). The PSC is one page, with 35 items, completed by parents or children, and designed to help clinicians in outpatient practice screen for school-age children with difficulties in psychosocial functioning. The PSC is included in
Bright Futures in Practice: Mental Health
and the Bright Futures Web site (
http://www.brightfutures.org/mentalhealth/pdf/professionals/ped_
sympton_chklst.pdf
) along with information on reliability and validity, scoring, and cutoff scores for referral.

The final area of history that requires review involves a history of the presenting symptom(s) by starting at the point the symptoms presented until the current time. This review of symptoms can be remembered using the PQRSTU mnemonic (Jarvis, 2007).

•   
Provocative or palliative:
What brings on symptoms? What makes them better or worse?

•   
Quality or quantity:
How intense are symptoms? What do the symptoms feel like?

•   
Region or radiation:
Where do they start? Do the symptoms spread?

•   
Severity scale:
Use an age-appropriate rating scale and ask what makes symptoms better or worse.

•   
Timing:
This includes onset, duration, and frequency of symptoms.

•   
Understanding:
Understand the child’s perception of the problem of concern.

Your review of Katie’s medical history shows that she does not have any chronic conditions and, except for otitis media as a preschooler, she has been seen only for routine preventive health care. As noted earlier, you last saw her for her 10-year-old health maintenance visit, and no physical or psychosocial problems were noted. She lives with her nuclear family—her father, who is an engineer; her stay-at-home mother; and an older brother who is in ninth grade. No other individuals live in the home. There have been no changes in the family health history. Her school screening questionnaire completed by her mother at the 10-year-old health visit indicated that she was receiving A’s and B’s in all subjects and enjoyed school. Her behavioral assessment with the PSC, also completed by her mother, fell within the normal range at that time, although Ms. Murphy reported that sometimes Katie worries, is afraid of new situations, and acts younger than her age.

Katie and her mom are present for the appointment. Katie sits close to her mom and seems distant with a flat affect. Upon questioning the reason for their visit today, initially Katie does not respond, and her mother answers your questions. Katie occasionally offers responses to direct questions but her responses are brief, single-word responses, usually yes or no, and with limited eye contact.

You then ask questions specific to the presenting complaint of stomachaches. Ms. Murphy reports that Katie has missed many days of school over the last 3 weeks due to stomachaches. The stomachaches begin in the morning but often appear to resolve by
late afternoon. Katie reports some nausea, but denies vomiting or diarrhea with the stomachaches. Her mother states she has not had any fevers over the last 3 weeks. Katie explains that her appetite is normal, yet her mother interrupts and reports that she does not seem to eat very much. You learn that Katie’s maternal grandmother passed away about 2 months ago from lung cancer but Ms. Murphy says that everyone seems to be coping well. No other recent family stressors were identified.

During the physical examination you ask Katie some more questions. Katie is hesitant to respond but states she started her menses 6 months ago and denies cramps that prevent her from doing her normal activities. Her mother confirms this information. Katie states that she feels tired at times, especially in the morning, but otherwise denies any other symptoms. She describes her stomachaches as hurting all over, but after she’s been up for awhile the pain goes away. She rates her pain as a 4 on a 0–10 pain scale where 0 is no pain and 10 is the worst imaginable pain.

Today’s physical exam reveals no fever, normal heart rate (HR) and blood pressure (BP), height is 59 inches, weight 95 pounds, and BMI 19.2 (64th percentile). Her abdomen is flat and nondistended with bowel sounds present in all quadrants, soft and negative for guarding with light and deep palpation. The remainder of the examination is negative. There are no indications for further lab or diagnostic tests at this time.

Your initial assessment suggests that Katie’s stomachaches are related to a psychosocial concern and her school absence behavior is possibly school refusal. You decide that you need to obtain further information.

What additional questions will you ask Katie and her mother as you consider the possibility of school refusal due to a psychosocial etiology?

Before answering this question, here is some information about school-age children who miss school that should be considered.

School Absence

Laws mandate school attendance. Children and adolescents are typically absent from school for reasons such as illness, appointments, special family events, religious holidays, or school-sanctioned activities. The National Center for Health Statistics (Bloom & Cohen, 2007) reports that in 2006 approximately 29% of students, 5 to 17 years of age, missed no school in the past year due to illness or injury, 29% missed 1 to 2 days of school, 36% missed 3 to 10 days, and 5% missed 11 or more days.

In addition to school absence due to legitimate reasons, children also miss school for reasons that are not acceptable to school and/or parents or guardians. Children who refuse to attend cause problems for themselves and concerns for parents, guardians, and school personnel. There has been some controversy over how to classify unauthorized school absences. Typically, unauthorized school absences have been categorized into two groups: 1) students who intentionally do not attend school, referred to as truancy; and 2) students who have difficulty
attending school associated with emotional distress (King & Bernstein, 2001), usually anxiety or fear, referred to as school avoidance, school refusal, or school phobia (Marcontel-Shattuck & Gregory, 2006). Truancy refers to absence from school that is initiated by the student and is not condoned by school officials, parents, or guardians. Truant students typically are not anxious, but instead, display a lack of interest in school and school rules, antisocial behaviors, and conduct problems (King & Bernstein; Marcontel-Shattuck & Gregory; Sewell, 2008). Students who do not attend school due to emotional distress have been further divided into three main clinical groups: anxious/depressed school refusers, separation-anxious school refusers, and phobic school refusers (Egger, Costello, & Angold, 2003; King & Bernstein). However, not all children who refuse to attend school are truant or anxious (Plante, 2007), and some have mixed school refusal behaviors (Egger et al.).