The primary mission of any school system is to educate students. To achieve this goal, the school district must maintain a culture and environment where all students feel safe, nurtured, and valued and where order and civility are expected standards of behavior. Schools cannot allow unacceptable behavior to interfere with the school district’s primary mission. To this end, school districts adopt codes of conduct for expected behaviors and policies to address unacceptable behavior. In developing these policies, school boards must weigh the severity of the offense and the consequences of the punishment and the balance between individual and institutional rights and responsibilities. Out-of-school suspension and expulsion are the most severe consequences that a school district can impose for unacceptable behavior. Traditionally, these consequences have been reserved for offenses deemed especially severe or dangerous and/or for recalcitrant offenders. However, the implications and consequences of out-of-school suspension and expulsion and “zero-tolerance” are of such severity that their application and appropriateness for a developing child require periodic review. The indications and effectiveness of exclusionary discipline policies that demand automatic or rigorous application are increasingly questionable. The impact of these policies on offenders, other children, school districts, and communities is broad. Periodic scrutiny of policies should be placed not only on the need for a better understanding of the educational, emotional, and social impact of out-of-school suspension and expulsion on the individual student but also on the greater societal costs of such rigid policies. Pediatricians should be prepared to assist students and families affected by out-of-school suspension and expulsion and should be willing to guide school districts in their communities to find more effective and appropriate alternatives to exclusionary discipline policies for the developing child. A discussion of preventive strategies and alternatives to out-of-school suspension and expulsion, as well as recommendations for the role of the physician in matters of out-of-school suspension and expulsion are included. School-wide positive behavior support/positive behavior intervention and support is discussed as an effective alternative.

Perhaps no public institution more closely mirrors the community in which it is found than does the public school system. The school system comprises children from a wide variety of socioeconomic backgrounds and a wide range of academic abilities and challenges. The primary mission of any school system is to educate the students for which it is responsible. To achieve this mission, the school district must maintain a culture and environment in which all students feel safe, nurtured, and valued. Order and civility must be maintained while expecting an appropriate standard of behavior from faculty, staff, and students. Traditionally, the goals for out-of-school suspension and expulsion policies were to promote a safe environment for students and staff by decreasing violent behavior, combating statutorily criminal activities (especially illicit drug usage and trafficking), and discouraging inappropriate behavior and limiting its influence on others. Out-of-school suspension and expulsion ensure that an offending act is punished; thus, in theory, a standard of acceptable behavior is maintained. It has been traditionally held that, in removing the offending student from the school environment, the student’s influence on others would be limited, the school environment would thereby be improved, and a message would be sent that certain behaviors will not be tolerated.1 Research has demonstrated, however, that schools with higher rates of out-of-school suspension and expulsion are not safer for students or faculty.2 

The Gun-Free Schools Act of 1994 (Pub L No. 103-882, §14601) popularized the concept of zero tolerance in the theory and practice of behavior control and discipline in schools and, in many cases, profoundly altered the entire discussion of these topics. As its title implies, that legislation focused specifically on the bringing of weapons to school and mandated a specific response from school districts. The offense for which the Gun-Free Schools Act was intended (that is, bringing a weapon to school) may account for <2% of the offenses for which students are suspended or expelled.3 Many school districts, however, quickly seized on zero-tolerance policies as a means of addressing a variety of infractions, including nonviolent offenses, such as drug and alcohol violations, verbal disrespect to teachers, and truancy. The concept of zero tolerance was readily embraced as inherently fair, and its harshness was accepted as a massive deterrent to undesirable behavior. However, problems with zero-tolerance policies began to occur soon thereafter, precisely because of its inflexibility and harshness. It is interesting to note that, although zero-tolerance legislation was prompted by violent acts perpetrated by white students, the vast majority of out-of-school suspension and expulsion occurring with zero-tolerance policy applications involve black or Hispanic students.2 

One of the first questions to surface was what “zero tolerance” should mean. A zero-tolerance policy that mandates a disciplinary hearing concerning certain unacceptable behaviors allows school boards and administrators flexibility and discretion in dealing with serious infractions. On the other hand, a policy that mandates a particular consequence (for example, that a student be suspended or expelled without consideration being given to the extenuating and mitigating circumstances of the case) allows authorities no such leeway. It should be noted that a school district may not want discretion in its zero-tolerance policy, feeling that such inflexibility sends the clearest message to offenders and best ensures the well-being of the rest of the student body. However, “research indicates a negative relationship between the use of suspension and expulsion and school-wide academic achievement, even when controlling for demographics such as socioeconomic status.”4 In other words, aggressive out-of-school suspension and expulsion policies may not only hurt those against whom they are applied but may also paradoxically hurt those students the policies were supposedly designed to protect and help. Problems with fairness, impartiality, uniformity, and flexibility have caused the effectiveness, validity, and justification of zero-tolerance policies to be questioned.2,4 Moreover, a student who has an individualized education plan (IEP) and/or has been identified with a disability may be entitled to a hearing to determine whether the student’s alleged misconduct was directly related to his or her disability or a direct consequence of the disability. The Individuals With Disabilities Education Act and relevant state statues should be referenced in this regard. If a student is thought to have a disability and is denied a hearing, the legality of such a denial may be open to question.

The adverse effects of out-of-school suspension and expulsion on the student can be profound. The student is separated from the educational process, and the school district may not be obligated to provide any further educational or counseling services for the student.5 Data suggest that students who are involved in the juvenile justice system are likely to have been suspended or expelled.4 Further, students who experience out-of-school suspension and expulsion are as much as 10 times more likely to ultimately drop out of high school than are those who do not.5,6 The student who does not complete high school can expect to earn considerably less over a working career and to have far fewer educational and employment opportunities from which to choose than a student who has completed high school. If the student’s parent(s) work, there may be no one at home during the day to supervise the student’s activity, making it more likely that the student (1) will not pursue a home-based education program; (2) will engage in more inappropriate behavior; and (3) will associate with other individuals who will further increase the aforementioned risks.2 

There are risks and disadvantages associated with the use of any powerful intervention or remedy, and out-of-school suspension and expulsion is no exception. Out-of-school suspension and expulsion are drastic responses to instances of severe misconduct. They can also be very superficial if, in using them, school districts avoid dealing with underlying issues affecting the child or the district, such as drug abuse, racial and ethnic tensions, and cultural anomalies associated with violence and bullying.7,8 There is also a risk of inconsistent and capricious application. In one 2006 study of statewide school suspension and expulsion rates, it was revealed that 10% of schools were responsible for 50% of suspensions.3,9 Moreover, “drastic” is not synonymous with “effective.” The Zero Tolerance Task Force of the American Psychological Association determined that schools with higher rates of suspension tend to have lower academic quality, pay less attention to school climate (social, cultural, academic, ethical), and receive lower ratings on school governance measures.4 Ironically, out-of-school suspension and expulsion often place the child back into the very environment that may have contributed to the antisocial behaviors in the first place, thereby negating the effectiveness of a “lesson-learned” from out-of-school suspension and expulsion. Atkins et al10 demonstrated that the use of suspension as discipline increased the number of students to whom suspension was applied, whereas when suspension was no longer used as punishment, that number declined.

Any discussion of a school district out-of-school suspension and expulsion policy must consider the fiscal implications of such a policy. Besides the loss of capitation funds for student attendance, there are other significant costs to the district associated with the process of suspending or expelling a student, including time spent in meetings, seeking expert testimony, and preparing for the disciplinary hearing itself. Unlike time spent by staff, consultants, and administrators working to educate children, time spent on suspension and expulsion preparation yields no measurable educational benefit, so it is especially costly to the district’s primary mission. Moreover, the cost to the district continues to mount after the expulsion hearing. States may require districts to have mechanisms whereby an expelled or suspended student receives services and may become eligible for reinstatement into the district, provided certain conditions are met and maintained.

Recalling that students who experience out-of-school suspension and expulsion are far more likely to ultimately drop out of high school, it is worthwhile to consider critically the potential adverse long-term fiscal consequences to the student and society as a whole. If the student does not graduate from high school, the long-term costs are profound. A high-school dropout will earn $400 000 ($485 000 for males) less over a lifetime than a high school graduate.11 The dropout will pay $60 000 less in taxes than the high school graduate. This represents a loss to federal and state governments of billions of dollars per year in income tax revenue. The average high school dropout experiences worse health12 than the average high school graduate and has a life expectancy that is 6 to 9 years shorter.13 The implications for the health care system are significant. For economic reasons alone, it is in the best interests of students and society to seek alternatives to out-of-school suspension and expulsion whenever possible.14 

As outlined previously, out-of-school suspension and expulsion represent an enormously costly and largely unsatisfactory solution to behavior problems in school, whether from the standpoint of the school district, the student, or the community. Out-of-school suspension and expulsion have short- and long-term consequences that are best avoided if at all possible.

Three strategies schools can use that can lessen the incidence of out-of-school suspension and expulsion are as follows: (1) early intervention programs for preschool children; (2) early identification of children at risk for school difficulties and intensive intervention before problem behaviors occur; and (3) annual implementation of clearly articulated and carefully taught age-appropriate codes of conducts with stated alternatives and supports for students to use before they engage in inappropriate behaviors, such as school-wide positive behavior support (SWBS). These strategies can also instill short- and long-term positive change in individual students and in the school district as a whole. It is important to note that they depend not just on the efforts of the school district, but on the coordinated resources of the entire community for their success.

The education of a community’s children is generally regarded as the responsibility of the local school district. The challenge and glory of the public school district is that it has an obligation to accept any and all children within its geographic boundaries into its programs. The school district does not, however, have much control over how well prepared children are to learn when they enter kindergarten at 4, 5, or 6 years of age. A great deal of neurocognitive development occurs in the first years after birth18; moreover, children who do not receive nurturing early in life or who are subject to stressful or toxic stimuli carry the effects of these adverse experiences for years afterward and may never be entirely free of their influence.19,22 Recent studies in infant and early child brain development have highlighted the critical influence of parenting, attachment, and early childhood education on the emotional, social, and cognitive development of young children and the role of attachment disturbances in many child and adult disorders. On the basis of these new developments, many communities have begun offering services such as nurse visits to at-risk pregnant women and parents, parenting programs, child care consultation, and therapeutic child care settings.23 Thus, meeting a child’s need for care and nurturing early on is critical to normal development and can have a significant effect on the child’s ability to adapt socially and succeed academically in school. Families and infants at risk for neglect and domestic violence can be identified by pediatricians and other care providers at prenatal visits and before discharge after delivery. Protocols to screen for and follow-up on at-risk families ensure fair and equitable treatment; many families in need may not fit a particular socioeconomic stereotype. Identified families should then be referred to public health and other community resources that can provide family support and services. These programs, which have been shown to be effective, at least with low-income families, play an important and, in some instances, essential role in promoting the positive functioning of families and ensuring the well-being of children.23 The American Academy of Pediatrics (AAP) report, “Preparing the Community for Addressing Mental Health Concerns,” provides resources to assist in determining which of these programs targeting young children are most promising.24 Pediatricians should become familiar with and make appropriate referrals to these programs as well as cooperative educational services and other public school universal pre-K or early education and child care programs that provide early childhood intervention to identified high-risk or at-need children. Early Head Start and Head Start programs are also important resources that pediatricians and other professionals can use for eligible families. Finally, children should be screened for medical and toxicologic etiologies that might result in behavioral problems, consistent with AAP Bright Futures guidelines.25 

Early identification and intensive intervention is a continuation of the efforts made during birth-to-preschool early intervention efforts. Ideally, this represents a coordinated effort among the primary pediatrician or specialists, the school district, and other community agencies to support families and children at risk. This support can come from many sources, including public health or social services agencies, service organizations such as Boys’ and Girls’ Clubs, local health care providers, and specialists at regional medical centers. In its 2004 policy statement, “School-Based Mental Health Services,” the AAP supports the development of school-based mental health programs as a means of “improving access to diagnosis and treatment for the mental health problems of children and adolescents.”26 Further research should be performed in this area to explore the question of whether mental health services would be more effective if provided in conjunction with a change in school-wide behavior expectations, as may be achieved through a program such as school-wide positive behavior support.

SWBS27,29 is based on group behavior theory; that is, behavior change occurs when desired behaviors are actively taught, clearly and consistently expected, and positively recognized and acknowledged. When SWBS is practiced, the proportion of students with serious behavior problems decreases, and the school’s overall climate improves. SWBS is based on 3 main components: (1) prevention; (2) multitiered support; and (3) data-based decision making. It comprises 3 tiers of intervention.1 The first focuses on school-wide primary prevention, involving all students, staff, and school settings. The second focuses on groups and students engaging in at-risk behaviors. The third tier focuses individualized intervention on students engaging in at-risk behaviors. The process is developed and driven by a group of 5 to 10 individuals representing administrators, staff, parents, community members, and students. This group learns the key practices of SWBS and develops the behavior goals to be achieved. All school staff members need to reinforce desirable behavior and be consistent in responding to such behavior and respond in a consistent fashion to such behavior.27 

Prevention involves defining and consistently teaching school behavior expectations and developing a consistent system to acknowledge and reward appropriate behavior.

Multitiered support refers to an equally consistent continuum of interventions for inappropriate behavior and supportive re-education for students who misbehave. Minor violations might entail a reminder to a student; a major violation would entail a specific intervention. These interventions may include (1) problem-solving and negotiation of a behavior contract; (2) in-kind restitution; (3) behavior-focused study courses or self-study modules; (4) parent involvement and “buy-in” in decision-making regarding their child’s schooling; (5) psychological evaluation and counseling; (6) community service (apart from restitution); (7) behavior monitoring based on the general tenets of the SWBS plan but tailored to the needs of the individual student; (8) coordinated behavior modification plans based on the general tenets of the SWBS plan but tailored to the needs of the individual student; (9) alternative programming, including curriculum, scheduling, site, and/or program, such as independent study or work-study; and (10) an appropriate in-school suspension program, which may be necessary to provide intensive supervision, academic tutoring, and behavior counseling. The goals of the in-school suspension program should be tailored to the needs of the student.30 Medical evaluation may also be considered.

Data-based decision-making refers to the practice of gathering aggregate data about student behavior and discipline issues for review by administration and the SWBS team. This analysis allows the development of strategies to reduce the problems identified.2 

The key to the SWBS approach is that it does not stress fixing the student’s past as much as it stresses the gains to be made by improving behavior in the future. In so doing, it does not make demands for counseling and psychological resources that the school district itself may not be able to provide; rather, it creates around each student and all students an environment of support such that even those students being disciplined can feel that it is being done supportively rather than punitively. It is cost-effective, not only in terms of demands on resources, but in terms of success. The effectiveness of SWBS is such that the US Department of Education, through its Office of Special Education Programs, established the Technical Assistance Center on Positive Behavior Interventions and Supports (PBIS) “to give schools capacity-building information and technical assistance for identifying, adapting and sustaining effective school-wide disciplinary practices.” Evidence-based analysis of results cited by school districts nationwide indicates that SWBS is effective in achieving these aims.31,33 More than 16 000 school districts nationwide have already adopted this approach to maintaining school discipline and reducing out-of-school suspension and expulsion, and most states have SWBS/PBIS (www.pbis.org). According to the Association for Positive Behavior Support “over 40 states have a state-level leadership team and action plan for PBIS implementation” (www.apbs.org). Some states have gone so far as to issue official statements citing the inequities and ineffectiveness of zero-tolerance policies and recommending SWBS models instead (Letter to Wisconsin Department of Public Instruction, Letter to Administration, March 2009).

A brief mention of bullying is made here because the problem of bullying among school children is receiving a great deal of well-deserved and overdue attention among various social and governmental institutions, and because SWBS/PBIS has been shown to be effective in addressing the problem of bullying as well. Effective management of bullying via SWBS is specifically addressed by the Technical Assistance Center on Positive Behavior Interventions and Supports.34 

The recently published AAP policy statement “Role of the Pediatrician in Youth Violence Prevention” addresses bullying defined as “a form of aggression in which 1 or more children repeatedly and intentionally intimidate, harass, or physically harm a victim who is perceived as unable to defend herself or himself.”35,37 The sociologic phenomenon of bullying is complex. Historically, it has been widely practiced and is the most common form of violence. Annually, 3.7 million youth engage in it and more than 3.2 million youth are victims annually.37 It involves essentially all children, as bullies, victims, or both or as knowledgeable bystanders. Put another way, few if any children are unaware whether bullying is occurring among their peers. Moreover, bullying has historically been ignored, condoned as “normal” or a “rite of passage,” and even modeled by adults. It has been suggested that schools themselves may encourage bullying through the widespread practice of labeling and separating students on the basis of physical or academic ability or limitation.38 Twenty-five percent of teachers in 2003 saw nothing wrong with bullying or harassment and intervened in only 4% of cases of bullying.38 Bullying among school-aged children, thus, represents an anomalous and distorted social norm, in which attitudes and behavior that would be unacceptable elsewhere in society are condoned or even encouraged.38 

A child’s ability to succeed in school depends, to a great extent, on factors affecting the child’s life well before the child begins school. Recognizing and addressing the socioeconomic and cultural risk factors affecting a child and the child’s family are essential to maximizing a child’s chances of success in school and to preventing, insofar as possible, the circumstances that may eventually lead to serious school behavior and discipline problems.

Out-of-school suspension and expulsion can contribute to the risk of a student dropping out of high school. The costs of a person’s failure to complete his or her secondary education are significant and are borne by society as a whole. These costs to society should be kept in mind as schools, communities, and states consider how to pay for medical, psychological, counseling, and other needed services for children at risk.

The AAP recognizes the importance of bringing the expertise of various professions to bear in a coordinated way to best help children who are not succeeding in school. More research is indicated to identify the most effective means of eliciting positive behaviors in a child with the greatest benefits to society.

Research continues to demonstrate that so-called zero-tolerance policies and out-of-school suspension and expulsion that are used too readily are ineffective deterrents to inappropriate behavior and are harmful and counterproductive to the student, the family, the school district, and the community as a whole, both short- and long-term.

The AAP does not support the concept of zero tolerance for the developing child. The AAP maintains that out-of-school suspension and expulsion are counterproductive to the intended goals, rarely if ever are necessary, and should not be considered as appropriate discipline in any but the most extreme and dangerous circumstances, as determined on an individual basis rather than as a blanket policy.

The aforementioned AAP policy statement “Role of the Pediatrician in Youth Violence Prevention” provides recommendations that are applicable to the reduction of youth violence and bullying and are consistent with the school-wide behavior modification programs that appear to be effective in reducing behaviors that lead to out-of-school suspension and expulsion.37 Beyond that, and especially in regard to out-of-school suspension and expulsion specifically, the pediatrician can play a variety of roles within the community and school district with respect to discipline issues:

  1. The pediatrician should screen for and recognize early childhood and preschool behavior problems. Once a pediatrician identifies a high-risk child, the pediatrician should refer the child to age-appropriate community resources, such as Birth to 3, Head Start, or other school district and community resources. Early identification of and intervention to address potential mental health concerns are critical.

  2. As the primary care physician to a school-aged student who is exhibiting problem behavior, the pediatrician should establish communication with the school nurse and/or counselor to verify how the child’s behaviors compare with peer behaviors in the school setting. The pediatrician should work with the school, the child and family, and most effectively, mental health care professionals to facilitate and coordinate care of the student. This should occur as early as possible in the onset of behaviors that fail to respond to standard interventions.

  3. The pediatrician should be familiar with safeguards as provided by the Individuals With Disabilities Education Act for those patients who have an IEP or 504 Plan. The pediatrician may act as an advisor, advocate, and mediator in special education IEP or 504 Plan meetings and disciplinary or manifestation hearings. The pediatrician should provide written documentation outlining bona fide need for medical accommodations to assist the school in providing reasonable assistance and therapeutic interventions.

  4. Pediatricians should become familiar with local school districts’ policies on out-of-school suspension and expulsion and zero tolerance. They should advocate for policy changes that support focus on prevention strategies and alternatives to out-of-school suspension and expulsion, such as positive behavior change programs both individually and school wide.

  5. The pediatrician can also serve in a larger capacity as a school district physician, a paid consultant, a medical advisor, or a local school board member to help develop school district policy regarding student behavior and discipline. Any professional services provided by a pediatrician on behalf of a specific student whether through diagnosis, treatment, counseling, or advocacy should be recognized as such and the pediatrician appropriately compensated.

Jeffrey H. Lamont, MD

Cynthia D. Devore, MD, Chairperson

Mandy Allison, MD, MSPH

Richard Ancona, MD

Stephen E. Barnett, MD

Robert Gunther, MD

Breena Holmes, MD

Jeffrey H. Lamont, MD

Mark Minier, MD

Jeffrey K. Okamoto, MD

Lani S. M. Wheeler, MD

Thomas Young, MD

Robert D. Murray, MD, Immediate Past Chairperson

Harold Magalnick, MD

George J. Monteverdi, MD

Rani S. Gereige, MD, MPH

Evan G. Pattishall III, MD

Michele M. Roland, MD

Mary Vernon-Smiley, MD, MPH – Centers for Disease Control and Prevention

Carolyn Duff, RN, MS, NCSN – National Association of School Nurses

Linda Grant, MD, MPH – American School Health Association

Veda Johnson, MD – National Assembly on School-Based Health Care

Linda Davis-Alldritt, RN, MA, PHN – National Association of School Nurses

Robert Wallace, MD – Independent School Health Association

Alex B. Blum, MD – Section on Residents

Sandi Delack, RN, MEd, NCSN – National Association of School Nurses

Madra Guinn-Jones, MPH

     
  • AAP

    American Academy of Pediatrics

  •  
  • IEP

    individualized education plan

  •  
  • PBIS

    positive behavior intervention and support

  •  
  • SWBS

    school-wide positive behavior support

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

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.

1
Technical Assistance Center on Positive Behavior Interventions and Supports, Office of Special Education Programs, US Department of Education. School-wide PBIS (positive behavior interventions and supports). Eugene, OR: Technical Assistance Center on Positive Behavior Interventions and Supports, Office of Special Education Programs, US Department of Education; 2009. Available at: www.pbis.org. Accessed October 17, 2012
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Opportunities Suspended: The Devastating Consequences of Zero Tolerance and School Discipline Policies. Cambridge, MA: Civil Rights Project, Harvard University; 2000. Available at: www.eric.ed.gov/ERICWebPortal/contentdelivery/servlet/ERICServlet?accno=ED454314. Accessed October 17, 2012
3
Sundis J, Farneth M. Putting kids out of school: what’s causing high suspension rates and why they are detrimental to students, schools and communities. Open Society Institute-Baltimore’s Student Attendance Series Policy Paper #2. Baltimore, MD: Open Society Institute; September 2008:2
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