Free Pediatric Primary Care Case Studies by Catherine E. Burns, Beth Richardson, Cpnp Rn Dns Beth Richardson, Margaret Brady Page B

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 difficultyattending 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.).
    Kearney and colleagues define school refusal behavior as “child motivated refusal to attend school and/or difficulties remaining in classes for an entire day” (Kearney & Albano, 2004, p. 147). This term thus encompasses all students who refuse to go to school, truants, those with anxiety-related disorders, and other unidentified reasons for school refusal, and does not focus on etiology but instead on behaviors. School refusal behavior occurs in all age groups, in boys and girls equally, and is reported to occur in from 1–5% of students (Fremont, 2003) to as many as 28% of students at some point in their school career