Suspension and expulsion from school are used to punish students, alert parents, and protect other students and school staff. Unintended consequences of these practices require more attention from health care professionals. Suspension and expulsion may exacerbate academic deterioration, and when students are provided with no immediate educational alternative, student alienation, delinquency, crime, and substance abuse may ensue. Social, emotional, and mental health support for students at all times in all schools can decrease the need for expulsion and suspension and should be strongly advocated by the health care community. This policy statement, however, highlights aspects of expulsion and suspension that jeopardize children’s health and safety. Recommendations are targeted at pediatricians, who can help schools address the root causes of behaviors that lead to suspension and expulsion and can advocate for alternative disciplinary policies. Pediatricians can also share responsibility with schools to provide students with health and social resources.
Suspension and expulsion from school are methods used by school administrators to decrease violence, discourage drug abuse, and curtail criminal activities on campus. Suspension and expulsion are also used to deal with difficult and challenging behaviors, including truancy.
Between 79% and 94% of schools have policies known as “zero tolerance”—the term given to a school or district policy that mandates predetermined consequences for various student offenses,1 and almost 90% of Americans support these policies.2 Despite widespread public support for schools’ zero tolerance disciplinary policies, the American Bar Association (ABA) voted in 2001 to recommend ending them. The ABA argues that it is wrong to mandate automatic expulsion or referral to juvenile court without taking into consideration the specifics of each case. It is understandably important for legal professionals to challenge a “one-punishment-fits-all” approach. It is equally important for pediatricians and related health care professionals to address potential physical health, mental health, and safety concerns that arise from suspension and expulsion from school.
Advocacy from the health care sector can be divided into 3 major categories. First and foremost, health care professionals need to advocate that the educational system provide, through its own system and through community partnerships, an environment and a range of resources that support students and that decrease the likelihood that students will engage in behaviors requiring disciplinary action. These recommendations are covered in the American Academy of Pediatrics policy statement “The Role of the Pediatrician in Youth Violence Prevention in Clinical Practice and at the Community Level.”3 In addition, “Mental Health in Schools: An Overview,”4 developed by the University of California Los Angeles Center for Mental Health in Schools, provides good references. A number of other published documents also exist on this subject, many of which are informative and comprehensive.5,6
The second category of health, mental health, and safety concerns is related to the lack of professional support and adult supervision often associated with suspension and expulsion. And third, discontinuity in education is an important concern, not least because educational success is so strongly linked to health and safety. Forty-nine percent of students in schools disciplined under a zero-tolerance clause are given out-of-school suspensions that last 5 days or more. Thirty-one percent are expelled, and 20% are transferred to an alternative school or program but often have out-of-school suspension periods up to 4 days in duration.1 Seventy-eight percent of schools in large urban school districts consider out-of-school or at-home suspension an acceptable disciplinary action.7
REASONS SCHOOLS APPLY OUT-OF-SCHOOL SUSPENSIONS
Real and perceived immediate threats to a student’s own safety or to the safety of others are some underlying reasons for out-of-school suspension. The Gun-Free Schools Act (Pub L No. 103-882) of 1994 requires schools to expel, for a period of not less than 1 year, students who have brought a weapon to school. However, this act also specifies that schools are allowed to provide educational services in alternative settings. Threat to safety logically should only apply to those students who have already caused serious injury or damage to school property or are at high risk of causing such injuries (eg, possession of a gun or explosive). However, studies of suspension and expulsion patterns suggest that danger of assault is not a major reason for students having been excluded from any school program. In 1997, of the 3.1 million students suspended from school, most were involved in nonviolent and noncriminal acts. Only approximately 10% of the expulsions or suspensions were for possession of weapons.8 In the small towns of states such as Oregon and South Carolina, students are expelled at 5 to 6 times the rates of students in cities such as Chicago and San Francisco, yet it is unlikely that crime rates in small towns are 5 times the rates in these large metropolitan areas.9
Excluding a student from attending school is sometimes imposed as a disciplinary tactic, intended primarily to punish the offender and secondarily to deter other students. School administrators have reported that removing a child from school provides a cooling-off period for the offending student as well as for frustrated educators and administrators. At-home suspensions are also sometimes seen as warnings for parents who may have not previously taken their child’s misbehavior seriously and who may have considered problem behaviors to be purely the school’s responsibility. Other school disciplinarians readily admit to using expulsion and suspension as tools to eliminate troublesome students from the educational system.10,11 In some states, no alternative educational setting is provided to suspended students. For example, in 1996–1997 in Massachusetts, 37% of expelled youth did not receive alternative education in another school or a special education program. In 75% of those cases, alternative education was not provided because the school district chose not to do so.12
Many school districts have developed alternative programs for students who are expelled or suspended. Unfortunately, in many of these circumstances, students are required to stay at home during an interim period ranging from days to months until arrangements can be made or a position becomes available in an alternative setting.
RISKS FACING SUSPENDED OR EXPELLED STUDENTS NOT IN SCHOOL
Children who are suspended are often from a population that is the least likely to have supervision at home. According to the 2000 US census, children growing up in homes near or below the poverty level are more likely to be expelled. Children with single parents are between 2 and 4 times as likely to be suspended or expelled from school as are children with both parents at home, even when controlling for other social and demographic factors.13 There may also be racial bias for application of school disciplinary actions, with African American youth suspended at nearly 2 times the rate of white students in some regions.14
Children who use illicit substances, commit crimes, disobey rules, and threaten violence often are victims of abuse, are depressed, or are mentally ill. As such, children most likely to be suspended or expelled are those most in need of adult supervision and professional help.15 In one study, 15% of children who have never been abused but had witnessed domestic violence were suspended from school in the previous year. This was attributed to heightened aggression and delinquency from living in a violent home environment.16 For students with major home-life stresses, academic suspension in turn provides yet another life stress that, when compounded with what is already occurring in their lives, may predispose them to even higher risks of behavioral problems.
Despite high rates of depression and numerous life stresses that are associated with school-based problem behaviors, students are not routinely referred to a medical or mental health provider on expulsion or suspension. The only exceptions are students requiring rehabilitation or drug testing when the cause of disciplinary action was related to substance abuse. Without the services of trained professionals (such as pediatricians, mental health professionals, and school counselors) and without a parent at home during the day, students with out-of-school suspensions and expulsions are far more likely to commit crimes. A Centers for Diseases Control and Prevention study found that when youth are not in school, they are more likely to become involved in a physical fight and to carry a weapon. Out-of-school adolescents are also more likely to smoke; use alcohol, marijuana, and cocaine; and engage in sexual intercourse.17 Suicidal ideation and behavior may be expected to occur more often at these times of isolation among susceptible youth. The lack of professional assistance at the time of exclusion from school, a time when a student most needs it, increases the risk of permanent school drop-out.9
Many school districts have been innovative with alternatives to out-of-school suspension and expulsion. Students are immediately transferred to supervised suspension classrooms run by the district until they are moved to an alternative setting or readmitted to their regular school site.18,19 In some districts, parents are required to accompany students to school for a portion of the school day. Some districts have students provide community service on school grounds during nonschool hours.
Although far from perfect, the statute for disciplinary action taken against students who are served by the Individuals With Disabilities Education Act (Pub L No. 101-476 ; ie, those who qualify for special education) presents a promising model for managing all young offenders in the educational setting. The law requires that students with disabilities, even if expelled, continue to receive educational services. The school must perform a preexpulsion assessment and demonstrate that it has made reasonable efforts to minimize the risk of harm in a student’s educational placement. These students’ individualized education programs are often specifically modified to address and prevent recurrence of inappropriate behavior.
Schools need to establish relationships with various health and social agencies in their communities so students with disciplinary problems who require assistance are readily referred and communication lines between these agencies and schools are established.
Students and their families should be encouraged by school staff members to access health care and social services, which can be accomplished if these important topics are included in health education and life skills curricula. It is also recommended that health care professionals provide information to children, youth, and families on access to health care and social services.
As part of the school’s or district’s written policy on disciplinary action, schools should routinely refer a student to his or her primary health care professional for an assessment if there is a disciplinary action or a student is at risk of such action. Assistance with obtaining a medical home should occur in circumstances in which a student facing disciplinary action does not yet have one.
Pediatricians should advocate for practices and policies at the level of the local school, the school district, and the state department of education to protect the safety and promote the health and mental health of children and youth who have committed serious school offenses.
Out-of-school placement for suspension or expulsion should be limited to the most egregious circumstances. For in-home suspension or expulsion, the school must be able to demonstrate how attendance at a school site, even in an alternative setting with a low ratio of highly trained staff to students, would be inadequate to prevent a student from causing harm to himself or herself or to others.
Matters related to safety and supervision should be explored with parents whenever their child is barred from attending school. This includes but is not limited to screening parents by history for presence of household guns.
Pediatricians should advocate to the local school district on behalf of the child so that he or she is reintroduced into a supportive and supervised school environment.
Pediatricians are encouraged to provide input to, or participate as members of, school- or district-based multidisciplinary student support teams that can provide disciplined students with a comprehensive assessment and intervention strategies. Schools should help support the participation of pediatricians on multidisciplinary teams by arranging for participation at times and in formats (eg, telephone) that are conducive to practicing healthcare professionals, by financially supporting time for school physicians, or through other logistic considerations.
A full assessment for social, medical, and mental health problems by a pediatrician (or other providers of care for children and youth) is recommended for all school-referred students who have been suspended or expelled. The evaluation should be designed to ascertain factors that may underlie the student’s behaviors and health risks and to provide a recommendation on how a child may better adapt to his or her school environment. A full history should be derived from the student, family members, and school staff members once consent to exchange information is attained. Management options to consider include appropriate referrals to drug rehabilitation programs, social agencies, mental health professionals, and other specialists who may assist with underlying problems. Pediatricians should routinely consider including school staff members as partners in the management of children and youth with school behavior problems, providing that privacy issues are respected as outlined in Health Insurance Portability and Accountability Act of 1996 (HIPAA [Pub L No. 104-191]) regulations.
Committee on School Health, 2002–2003
*Howard L. Taras, Chairperson
Barbara L. Frankowski, MD, MPH
Jane W. McGrath, MD
Cynthia J. Mears, DO
Robert D. Murray, MD
Thomas L. Young, MD
Janis Hootman, RN, PhD
National Association of School Nurses
Janet Long, MEd
American School Health Association
Jerald L. Newberry, MEd
National Education Association, Health Information Network
Mary Vernon-Smiley, MD, MPH
Centers for Disease Control and Prevention
Su Li, MPA
↵* Lead author
Policy Statement: Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
- ↵US Department of Education, National Center for Education Statistics. Violence and Discipline Problems in U. S. Public Schools: 1996–97. Washington, DC: US Government Printing Office; 1998
- ↵Rose LC, Gallup AM. The 30th Annual Phi Delta Kappa/Gallup Poll of the public’s attitudes toward the public schools. Phi Delta Kappan.1998;80 :41– 56
- ↵American Academy of Pediatrics, Task Force on Violence. The role of the pediatrician in youth violence prevention in clinical practice and at the community level. Pediatrics.1999;103 :173– 181
- ↵University of California Los Angeles, Center for Mental Health in Schools. Mental Health in Schools Web site. Available at: http://smhp.psych.ucla.edu/aboutmhinschools.htm. Accessed March 31, 2003
- ↵Bell CC, Gamm S, Vallas P, Jackson P. Strategies for the prevention of youth violence in Chicago Public Schools. In: Shafii M, Shafii SL, eds. School Violence: Assessment, Management, and Prevention. Washington, DC: American Psychiatric Press; 2001:251–272
- ↵Weissberg RP, Greenberg T. School and community competence enhancement and prevention programs. In: Sigel IE, Renninger KA, eds. Handbook of Child Psychology. Vol 4: Child Psychology in Practice. 5th ed. New York, NY: John Wiley & Sons; 1998:877–954
- ↵American Federation of Teachers. Survey of Discipline Codes in Large City School Districts, August 1995. Washington, DC: American Federation of Teachers; 1996. Available at: http://www.aft.org/research/reports/collbarg/discplin/settings.htm. Accessed November 18, 2002
- ↵Legislative Analyst’s Office, State of California. Juvenile Crime: Outlook for California. Sacramento, CA: Legislative Analyst’s Office; 1995. Available at: http://www.lao.ca.gov/kkpart3.html. Accessed December 10, 2002
- ↵Brooks K, Schiraldi V, Ziedenberg J. School House Hype: Two Years Later. Washington, DC: Justice Policy Institute and the Children’s Law Center; 2000
- ↵Bowditch C. Getting rid of troublemakers: high school disciplinary procedures and the production of dropouts. Social Problems.1993;40 :493– 509
- ↵Massachusetts Department of Education. Student Exclusions in Massachusetts Public Schools: 1996–97. Malden, MA: Massachusetts Department of Education; 1998
- ↵Maryland State Department of Education, Information Management Branch. Suspensions From Maryland Public Schools, 1998–1999. Baltimore, MD: Maryland State Department of Education; 1999
- Copyright © 2003 by the American Academy of Pediatrics