School Suspension and Expulsion: Policy Statement

Exclusionary school discipline represents practices that remove a student from their usual educational setting, either temporarily (suspension) or permanently (expulsion). Suspensions can be further classified as in-school or out-of-school. For the purposes of this policy statement, the word “student” refers to children and adolescents enrolled in preschool, kindergarten, and grades 1 through 12. According to the most recent data available from the 2020 to 2021 school year, more than 1.4 million students in kindergarten through grade 12 were suspended at least once (55% in-school, 45% out-of-school), and more than 28 000 students were expelled.¹  With consideration of the impact of the coronavirus disease 2019 pandemic on schools, data collected from the 2017 to 2018 school year are also presented here, with more than 2.5 million students in kindergarten through grade 12 suspended at least once, and more than 100 000 students expelled.²  Exclusionary school discipline was once reserved for a small percentage of students demonstrating unsafe behavior. However, from 1973 to 2006, the percentage of students disciplined with suspension or expulsion increased from 3.7% to 6.9% of total student enrollment.³  The adoption of zero-tolerance discipline policies in the early 1990s is believed to be a key contributor to the increase in suspensions and expulsions.⁴ 

A zero-tolerance policy creates a chain of events in which a specific undesired behavior triggers a mandated and predetermined punishment, without consideration of the situational context surrounding the behavior.⁴  This ideology became prominent during the “War on Drugs” campaign in the 1970s, resulting in the creation of mandatory minimum sentences, “truth-in-sentencing” laws, and “3 strikes” policies.⁵  The same year that a federal “3 strikes” bill was signed into law, zero-tolerance policies were implemented in most schools across the country, allowing administrators to mandate predetermined consequences for various problematic student behaviors.

A notable example of a zero-tolerance exclusionary school discipline practice was the Gun-Free Schools Act of 1994; this federal law was passed in response to firearm violence, particularly mass shootings, on school grounds.⁶  It required a minimum 1-year expulsion for any student who brought a firearm to school; it also mandated law enforcement be notified of the incident.⁷  This landmark zero-tolerance policy created a precedent for schools to implement suspension and expulsion practices for a broad array of undesired behaviors.⁸ 

In the years that followed the Gun-Free Schools Act, exclusionary school discipline rates rose to a peak of nearly 3.2 million students suspended at least once (6% of total national enrollment) during the 2011 to 2012 school year.⁹  Currently, the most common indications for suspension and expulsion are for behaviors that are neither violent nor criminal.¹⁰  A particularly counterproductive indication for exclusionary school discipline is truancy.¹⁰  In this case, students who already lost instructional time because of repeated unexcused absences are then suspended, which further decreases educational access and increases risk of academic disengagement.¹⁰ 

It is indisputable that schools have a responsibility to create a safe learning environment for their students. Limiting exclusionary school discipline while ensuring school safety is a task with health equity and educational considerations. There is little evidence that zero-tolerance school exclusion policies make schools safer.⁴  According the National Center for Education Statistics, there were approximately 12 times more school shootings with casualties during the 2021 to 2022 school year than there were in the 2000 to 2001 school year.¹¹  In addition, suspension and expulsion alone are often not effective in deterring future misbehavior. During the 2020 to 2021 school year, 28% of suspended students were suspended more than once in the same school year,¹  suggesting that many students who are suspended are often not receiving the appropriate support they need to create lasting behavioral change.

It should be noted that suspensions and expulsions are not always used in the specific context of zero-tolerance discipline policies. For example, exclusionary school discipline may be used for chronic discipline referrals.¹⁰  Administrators and teachers may use subjectivity and personal judgment when determining which behaviors warrant exclusion from school, and this decision-making process may be influenced by their biases.¹⁰ 

An intersectional approach is taken to jointly consider disparities in exclusionary school discipline in the context of a student’s race, ethnicity, gender, sexual orientation, socioeconomic status of caregivers, and ability. Students with multiple marginalized identities are at particularly high risk for suspension and expulsion.¹²  Of note, students disproportionately affected by exclusionary school discipline policies often belong to populations with a high prevalence of childhood trauma.¹³  In the absence of protective interpersonal relationships and other supportive factors that build resilience, students affected by childhood trauma can develop maladaptive coping skills that manifest in the classroom as inattention, impulsivity, emotional lability, and impaired executive function.¹³ 

More than 20 years of multidisciplinary literature has demonstrated that Black children and adolescents are among those students most severely affected by disparities in exclusionary school discipline practices.¹⁰  Despite representing only 17% of preschool enrollment from 2020 to 2021, Black toddlers received nearly one-third of all preschool suspensions and one-quarter of all preschool expulsions.¹⁴  By age 9, about 40% of Black boys and 15% of Black girls who live in urban areas have already been suspended or expelled at least once.¹⁵ 

Implicit bias and racial stereotypes may contribute to how Black students are disciplined in school.¹⁰  There is no evidence that Black students misbehave at higher rates than other students.¹⁶  Black children do not commit more serious infractions than their peers and are more likely to be disciplined for subjective infractions, such as loitering, creating excessive noise, and being disrespectful and threatening.¹⁷  In addition, Black children have experienced school discipline for their hair texture and for wearing protective hairstyles, prompting California to be the first state to ban hair discrimination in schools with passage of the 2019 CROWN Act.¹⁸  Teachers in a controlled experiment were more likely to judge committing 2 minor infractions as evidence of an underlying troubling behavioral pattern when these infractions were committed by Black children as compared with white children.¹⁹  Consequently, these teachers were more likely to recommend harsher punishments for Black students than for white students.¹⁹  This discrepancy could be attributable in part to the “adultification” of Black children and adolescents, who are perceived to be older and less innocent than other children their same age.^20,21  The American Academy of Pediatrics (AAP) policy statement “The Impact of Racism on Child and Adolescent Health” provides additional information on how systemic racism affects child development and health outcomes in affected pediatric populations.²² 

American Indian/Alaska Native (AI/AN) students are also disproportionately impacted by exclusionary school discipline. At the state level, American Indian students in California, Montana, and Utah are 2.4 to 4 times more likely to receive a suspension than white students.^23–25  Further research is needed regarding the experiences of suspended and expelled AI/AN students.

Socioeconomic status of caregivers, student gender, and student sexual orientation may play a role in who is most affected by exclusionary school discipline. Students who are eligible for free or reduced-price lunch at school are suspended at a higher rate than other students.²⁶  Boys are more likely to be suspended or expelled than girls, with boys receiving more than 70% of expulsions in the 2020 to 2021 school year.¹⁴  Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) students are also suspended and expelled at higher rates than their peers.¹⁰  Examples of challenges for LGBTQ + students may include being provoked to physical fighting in response to bullying and being expected to follow gender-norm dress codes that may be incongruent with gender identity.²⁷  In addition, LGBTQ + children and adolescents experience disproportionately high rates of physical violence and substance use; the AAP policy statement “Office-Based Care for Lesbian, Gay, Bisexual, Transgender, and Questioning Youth” provides additional information on health disparities and challenges faced by LGBTQ + youth.²⁸ 

In addition, students with disabilities—ie, students served by the Individuals with Disabilities Education Act (IDEA) or Section 504—are disproportionately affected by exclusionary school discipline.¹  Students identified under the IDEA categories of “emotional disturbance” (ED), “intellectual disability,” and “other health impairment”—eg, attention-deficit/hyperactivity disorder (ADHD)—are at highest risk for suspension and expulsion among all students with disabilities.²⁹  In addition, students with ED and ADHD are more likely to be suspended or expelled repeatedly.²⁹  Individual student factors, such as increased impulsivity, irritability, and inability to anticipate consequences, likely play a role in how students with disabilities are disciplined in school.¹²  A lack of educational services resulting from exclusionary school discipline can impede academic achievement in this population, particularly for students with an Individualized Education Program (IEP) or Section 504 plan who rely on special education services or in-school supports.

Numerous studies have demonstrated the importance of early childhood education and its associations with improved health across the lifetime of the child.³⁰  These effects are due in part to promotion of positive cognitive and noncognitive skills during early education that help a child develop executive functioning, social learning, and self-regulation.³⁰  During the 2020 to 2021 school year, nearly 1000 preschool students received 1 or more suspensions, and 220 preschool students were expelled.¹  Exclusionary school discipline in this early education period imposes a harsh penalty for behaviors that are likely still developmentally appropriate for the child, such as the inability to manage strong emotions in the classroom setting. Unsurprisingly, suspension and expulsion of preschoolers is largely ineffective in decreasing physically aggressive behavior.¹⁵  Repeated preschool suspensions and expulsions can exacerbate poverty and food insecurity by requiring caregivers to find costly alternative child care services or take leave from work. Exclusionary school discipline in this period can also interrupt child routines and impose stigmatizing labels on young children.

Exclusionary school discipline is associated with school failure, which can limit career opportunities and put students at risk for worse health outcomes; this is known in the literature as the education-health gradient.³¹  Many suspended and expelled students experience decreased instructional time, disruption in student-teacher relationships, and lack of adult supervision while removed from the school environment.¹⁰  These factors can contribute to academic disengagement and low academic achievement. Suspended and expelled students are more likely to drop out of high school, which severely stunts their lifetime earning potential.^10,31  An individual’s level of education is a known social determinant of health, and inability to obtain a high school diploma is associated with a multitude of negative health outcomes, including increased rates of mortality from cardiovascular disease.³² 

More than 20 years of multidisciplinary research has demonstrated that exclusionary school discipline greatly increases a child’s likelihood of being involved in the juvenile justice system, even as early as during the same month the child is suspended or expelled.^33,34  This phenomenon is known as the “school-to-prison pipeline.”³⁴  Being out of school and without adult supervision likely creates more opportunities for a child to be involved in criminal activities. A Centers for Disease Control and Prevention study found that when youth are not in school, they are more likely to use recreational drugs, engage in a physical fight, and carry a weapon.³⁵  The number of arrests of children per year is staggering; in 2020, more than 424 000 children were arrested, and nearly 122 000 of those children were younger than 14.³⁶ 

The school-to-prison pipeline can create a vicious cycle of incarceration, release, and rearrest. Once a child is incarcerated, they have up to an 80% chance of rearrest within 3 years of their initial release, depending on the state in which they reside.³⁷  In addition, 40% of young people with a history of juvenile incarceration will be reincarcerated in an adult prison by age 25.³⁸  These periods of imprisonment leave little time for completion of high school education, contributing to a markedly increased risk of dropping out of high school.

There are notable racial and ethnic disparities in the school-to-prison pipeline. A recent study from the Office of Juvenile Justice and Delinquency Prevention demonstrated that Black youth are 4.7 times more likely than white youth to be placed in custody of the juvenile justice system.³⁹  This mirrors the racial and ethnic disparities in the adult justice system, with Black people making up 13.7% of the general population but representing 38.9% of the incarcerated population.^40,41  Differential offending and differential treatment are two theoretical frameworks that have been used to examine why these racial and ethnic disparities exist for Black children and adolescents.⁴²  The differential offending framework notes that Black children and adolescents have increased individual and environmental risk factors for juvenile justice involvement, which include greater exposure to community violence, enrollment in low-performing schools, and having incarcerated and/or deceased parents.⁴²  The differential treatment framework recognizes that there are internal factors within the juvenile justice system that contribute to racial and ethnic disparities, such as increased police patrolling in neighborhoods where Black youth live and the perception of Black youth as a threat by decision-makers.⁴² 

Involvement with the juvenile justice system is an adverse childhood experience and a source of childhood trauma. Children involved in the juvenile justice system have an increased risk of developing asthma, hypertension, mood disorders, sexually transmitted infections, unplanned pregnancies, and substance use disorders.^43,44  In addition, children involved in the juvenile justice system are a medically vulnerable population that typically lacks access to pediatric primary care, instead relying on costly safety net systems, such as emergency departments.⁴⁵  The AAP policy statement “Advocacy and Collaborative Health for Justice-Involved Youth” provides a thorough review of the health challenges of justice-involved youth.⁴⁴ 

Of note, the cost of juvenile incarceration is significantly higher than the cost of public education. The average cost to states for youth incarceration is about $214 000 per child per year.⁴⁶  By contrast, the average amount spent by the K-12 public education system is about $16 280 per student per year.⁴⁷  In addition, indirect costs to society include lost future earnings, the opportunity cost of unemployment, and lost state and federal tax revenue. Keeping students in school not only is better for their health and future opportunities but also is a better fiscal choice for taxpayers.

School climate refers to the quality and character of school life; it is the organizational culture that helps students feel safe and respected.⁴⁸  Exclusionary school discipline has a negative effect on school climate, and high rates of suspension and expulsion are correlated with lower academic achievement schoolwide.^10,49  School security measures may also negatively impact school climate, especially for students who identify as part of historically marginalized communities.⁵⁰  Black students and students whose caregivers have low socioeconomic status are more likely to experience metal detectors, video surveillance, and random property searches while at school, as well as interact with school resource officers (SROs).⁵¹  SROs are sworn law enforcement officers who are tasked with promoting school safety and are trained in adolescent behavior, crisis management, and trauma-informed de-escalation techniques.⁵²  When in-school arrests occur by SROs, AI/AN students, Black students, boys, and students with disabilities have a higher risk of being arrested than other students.¹⁴ 

A coalition of students, families, pediatric health care providers, education leaders and their unions, and leaders in juvenile justice reform would be well-positioned to create alternatives to exclusionary school discipline practices as well as identify and support students disadvantaged by suspension and expulsion.

The toxic stress framework is well demonstrated in the literature, explaining how prolonged or significant childhood adversity has the potential to create a wide array of biological changes associated with negative adult health trajectories.^13,53  Exclusionary school discipline, particularly when used repeatedly and in the absence of relational buffers, can be a source of prolonged or significant adversity for children and adolescents. Pediatric health care providers can help reduce the risks and harms of suspension and expulsion through use of surveillance or screening practices, partnering with caregivers to promote relational health, making referrals for trauma-informed therapies, and participating in advocacy work. Any pediatric health care provider who sees children and adolescents longitudinally can be impactful in this work, including primary care or complex care pediatricians, subspeciality pediatricians, pediatric nurse practitioners, pediatric physician assistants, and other pediatric health care providers.

Per AAP and Bright Futures guidelines, pediatric health care providers can screen for social determinants of health that are specifically linked with school difficulty in the literature, including food insecurity, unsafe and unstable housing, maltreatment, and witnessed interpersonal violence.⁵⁴  In addition, pediatric health care providers can screen for chronic absenteeism, ie, missing 15 or more school days a year, as chronic absenteeism is associated with school difficulty and school dropout.⁵⁵  Many community-based agencies and organizations exist to address these issues, and the pediatric health care provider has an essential role in placing referrals and recommending these practical resources to benefit students and their families.

Students with disabilities, especially students with ED, intellectual disability, and ADHD, are at higher risk for exclusionary school discipline.²⁹  The AAP and Bright Futures guidelines recommend screening children and adolescents for behavioral and socioemotional issues annually using a family-centered approach.⁵⁶  When developmental concerns are identified, pediatric health care providers can refer to early intervention services, special education services, and/or a developmental-behavioral pediatrician when indicated.⁵⁷  Caregivers are often excellent advocates for their children to be evaluated by the school district for an IEP or Section 504 plan; pediatric health care providers can be an additional resource to help families navigate these processes. When behavioral health concerns are identified, pediatric health care providers can refer to mental health providers, including referrals for trauma-focused cognitive behavioral therapy. With regard to children and adolescents with substance use concerns, an AAP clinical report outlines screening, brief interventions, referrals, and treatments.⁵⁸ 

In 2021, the AAP, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association released a “Declaration of a National Emergency in Child and Adolescent Mental Health.”⁵⁹  This was issued in response to the rising rates of mental health concerns and suicide during the coronavirus disease 2019 pandemic that was compounded by a shortage of mental health providers.⁵⁹  Pediatric health care providers can advocate for increased access to mental health services through legislation, eg, Texas SB 11 created the Texas Mental Health Consortium.⁶⁰  The consortium operates Texas Child Access Through Telemedicine, which provides no-cost care to public school students through telemedicine.⁶¹  In addition, pediatric health care providers can advocate for expansion and sustainable funding of school-based mental health services. Students are 6 times more likely to access evidence-based services in schools than in the community, and expansion of these services would promote appropriate professional-to-student ratios of counselors, psychologists, social workers, school nurses, and other staff.⁶² 

For children and adolescents already affected by school suspension or expulsion, the pediatric health care provider can take a family-centered approach to best support students and their families. Pediatric health care providers can empower caregivers to challenge the local education agency (LEA) and seek legal assistance if the caregiver believes the suspension or expulsion is inappropriate. Pediatric health care providers can also encourage caregivers to advocate for the student to continue receiving quality educational services while removed from the school environment.

LEAs already recognize the special protections for students served by the IDEA—ie, those who qualify for special education.^63,64  Students protected by IDEA cannot be suspended for more than 10 days without a meeting to review the individual’s behavior in the context of their disability and their IEP.⁶³  In addition, if a student with an IEP is suspended for more than 10 days, schools are mandated to provide free appropriate public education even if the student is already in an alternative placement setting.⁶³ 

Distance and remote learning processes could have a role in filling temporary educational gaps, although accessing remote learning can be an additional challenge for families, and further research is needed to assess the efficacy of these methods. If remote learning is not an option, the school can provide class assignments and homework for the excluded student to work on from home. Some states already have legislation to support this—eg, California Assembly Bill 982 requires schools to provide homework assignments to students who are suspended for 2 or more school days.⁶⁵  It is important that alternative educational services are provided to suspended and expelled students to avoid gaps in education and academic disengagement.

Finally, pediatric health care providers can be powerful advocates for educational and juvenile justice reform. They can familiarize themselves with their school district’s existing school discipline practices and promote available alternatives to suspension and expulsion through legislative advocacy. They can support legislation that prohibits suspension and expulsion from federal and state-funded preschools and child care programs. They can also advocate for the creation and maintenance of community programs for children released from the juvenile justice system to prevent recidivism. Finally, pediatric health care providers can serve as liaisons or representatives on school boards or other organizations dedicated to issues around exclusionary school discipline and juvenile justice.

In 2014, the US Department of Education and the US Department of Justice released a joint “Dear Colleague Letter on the Nondiscriminatory Administration of School Discipline.” The purpose of this document was to provide guidance to public schools on how to address current disparities in exclusionary school discipline.⁶⁶  This document was rescinded in 2018 with the change in federal administration and is currently under review.⁶⁶  Since 2014, school administrators, teachers, and educational staff have made admirable gains in reducing overall suspension and expulsion rates.¹⁴  However, disparities in exclusionary school discipline have remained persistent.¹⁴ 

LEAs can help reduce the risks and harms of exclusionary school discipline through internal collection and analysis of disaggregated data regarding their suspension and expulsion practices. One successful model is the Office of the State Superintendent of Education in Washington, DC, which has required LEAs in the District of Columbia to submit annual exclusionary school discipline data since 2013.⁶⁷  Collected data could include school demographics and disciplinary incident reports with their outcomes, including office referrals, disparity data, schoolwide academic performance, high school graduation rates, referrals to law enforcement, juvenile justice system involvement, and other outcomes. Data about “informal removals” may be also needed, ie, sending students with disabilities home early repeatedly or other practices that shorten their academic day; these disciplinary practices limit instructional time without the formal administrative process of suspensions and expulsions.⁶⁸  In addition, it might be useful to collect data on corporal punishment, restraint, and seclusion in schools because these discipline policies are also used disproportionately for AI/AN students, Black students, and students with disabilities.^69,70  Collecting school climate survey data with participation from students, families, teachers, administrators, school resource officers, and other school staff can give LEAs insight into the varied experiences of both children and adults in their schools. Using these data to create a publicly available discipline report could increase transparency among members of the school community and inform LEA policy changes.

LEAs can use discipline reports to determine areas for improvement in school personnel training and professional development. Given the current disparities in exclusionary school discipline regarding race, ethnicity, gender, sexual orientation, socioeconomic status, and ability, universal antibias training for staff could be beneficial. Antibias training is most effective when it is tailored to the specific needs of the school and when it generates actionable strategies for school staff based on their roles.⁷¹  Effective institution-wide equity, diversity, and inclusion plans typically incorporate antibias training along with other measurable equity, diversity, and inclusion benchmarks, such as hiring and retention of diverse teachers.⁷¹  LEAs can consider including other areas of professional development as needed to create a safe and inclusive educational environment, such as conflict resolution, de-escalation approaches, and social-emotional training.

LEAs can also use information from discipline reports to promote safe, inclusive, and positive school climates. There is growing evidence that positive school climates are associated with less exclusionary school discipline, likely because the relationships between administrators, teachers, school staff, students, and families are strengthened.¹⁰  The proposed mechanisms for promoting a positive school climate include trauma-informed school practices, multitiered system of supports (MTSS), and restorative practices, which are discussed in further detail below. In addition, schools have an important role in engaging and partnering with students and their families to create a positive school environment.

The federally funded National Child Traumatic Stress Network defines a trauma-informed system as an entity in which “all parties involved recognize and respond to the impact of traumatic stress on those who have contact with the system, including children, caregivers, and service providers.”⁷²  The National Child Traumatic Stress Network created a system framework for trauma-informed schools, consisting of 10 core principles to be used as both a preventive approach and as a tiered support system for students already affected by trauma.⁷²  An example of trauma-informed school practices is the Kaiser Permanente Resilience in School Environments program, which successfully provided educators with practical tools to regulate stress, identify feelings, and reframe challenging interactions using a trauma-informed lens.⁷³ 

School climate can also be improved by supportive frameworks, such as MTSS and restorative justice. All MTSS frameworks take a proactive approach that assists educators in providing the academic, social, emotional, and behavioral strategies to support students at their individual level of need.⁷⁴  One example of MTSS is positive behavioral interventions and supports (PBIS). PBIS is a 3-tiered model to closely pair the severity of a student’s behavioral and academic needs with an appropriately intense intervention; the 3 tiers can be thought of as universal, targeted, and intensive supports.⁷⁴  This model aims to prevent inappropriate behaviors by setting clear behavior expectations and promoting positive behaviors.⁷⁴  A growing body of evidence suggests that PBIS decreases overall suspension and misbehavior rates and improves social-emotional functioning.⁷⁵  One caveat is that PBIS does not appear to reduce racial and ethnic disparities in exclusionary school discipline policies.⁷⁵  This caveat suggests the opportunity for implementation of a framework of PBIS that is specifically culturally responsive and addresses implicit bias.

Restorative practices is another evidence-based model that can improve school climate and reduce racial and ethnic disparities in exclusionary school discipline.^76,77  Restorative practices is an intervention that aims to repair relationships between the person harmed, the responsible person, and the school community as a whole through various exercises, such as conflict and harm mediation and community-building circles.⁷⁶  Maryland’s House Bill 1287 established the Maryland Commission on the School-to-Prison Pipeline and Restorative Practices in 2017, resulting in positive changes to school climate for schools that use restorative practices.⁷⁷  For example, Maryland’s LEAs have reported a decrease in suspensions and an increase in student conflict resolution skills and classroom participation with the implementation of restorative practices in schools.⁷⁷ 

It may be difficult for pediatric health care providers to participate in this work because of their office visit time constraints, provider burnout, and other challenges. School-wide tiered supports, such as PBIS, rely on having sufficient numbers of counselors, psychologists, social workers, school nurses, and other providers to implement tiers of support and maintain appropriate student-to-staff ratios. Under-resourced schools that already face budget cuts related to staffing may find adapting these programs particularly challenging, although advocacy from students, school staff or educators’ unions, and community partners can successfully generate political will to enact reform. For example, the aforementioned groups had an essential role in the Los Angeles Unified School District allocating $25 million to fund their Black Student Achievement Plan.⁷⁸  The Black Student Achievement Plan includes funding for hiring restorative practices teachers, school climate advocates, psychiatric social workers, and other key staff members.⁷⁹  For LEAs, the processes of data collection, school personnel training, and promoting positive school climates will require significant time, leadership buy-in, partnership with families, and funding.

The AAP recommends that pediatric health care providers do the following:

1. Understand the current disparities in the use of suspension and expulsion, particularly for AI/AN students, Black students, students whose caregivers have low socioeconomic status, male students, LGBTQ+ students, and students with disabilities, and refer affected students to education advocacy services.

2. Acknowledge that suspension and expulsion in the early education period is developmentally inappropriate and can create harm by interrupting child routines, imposing stigmatizing labels, and exacerbating caregiver stress because of employment and child care challenges.

3. Identify the potential harms of school suspension and expulsion to the affected student, including missed instructional time, increased risk of school failure, and increased contact with the juvenile justice system.

4. Understand how dropping out of high school and juvenile justice involvement are pertinent risk factors associated with worse physical and mental health outcomes in affected children and adolescents throughout their lifetime.

5. Refer families to government and community resources, including trauma-informed care systems, that address the social determinants of health associated with school difficulty, including food insecurity, unsafe and unstable housing, maltreatment, and witnessed interpersonal violence.

6. Screen school-aged children for chronic absenteeism, ie, missing 15 or more school days a year, as chronic absenteeism is associated with school difficulty and school dropout.

7. Screen all children and adolescents for developmental delays and disabilities that may lead to school difficulty, and refer to developmental-behavioral pediatricians, early intervention services, and/or special education services in a timely manner.

8. Educate caregivers of students with disabilities on the processes to develop an IEP or a Section 504 plan with the student’s school.

9. Stay informed on AAP policy and practice guidelines for the screening and treatment of developmental and mental health problems, including substance use.

The AAP recommends that pediatric health care providers do the following:

1. Advocate for increased access to mental health services for all students, acknowledging the current Declaration of a National Emergency in Child and Adolescent Mental Health.

2. Advocate for expansion and sustainable funding of school-based mental health services with appropriate professional-to-student ratios to increase access to evidence-based mental health services.

3. Support legislation that prohibits suspension and expulsion from federal and state-funded preschools and child care programs.

4. Advocate for legislation that requires schools to provide educational services to all children and adolescents who are suspended or expelled, either through remote learning or through homework assignments.

5. Advocate for continued school district funding for programs that offer alternatives to exclusionary school discipline, particularly on the behalf of underresourced schools.

The AAP recommends that local education agencies do the following:

1. Collect and analyze internal disaggregated data regarding exclusionary school discipline practices.

2. Offer universal antibias training for administrators, teachers, school resource officers, and other school staff to decrease bias related to race, ethnicity, gender, sexual orientation, socioeconomic status of caregivers, and ability.

3. Determine areas for improvement in school personnel training and professional development, including conflict resolution, de-escalation approaches, and social-emotional training.

4. Promote positive school climates by partnering with families and utilizing interventions such as trauma-informed school frameworks, multitiered system of supports programs including positive behavior interventions and supports, and restorative practices.

5. Recognize the special protections for students served by the Individuals with Disabilities Education Act (IDEA) or Section 504 when they are suspended or expelled.

6. Advocate for continued school district funding for programs that offer alternatives to exclusionary school discipline, particularly on the behalf of under-resourced schools.

Susanna K. Jain, MD, FAAP

Nathaniel Beers, MD, MPA, FAAP

Ryan Padrez, MD, FAAP

Sonja C. O’Leary, MD, FAAP, Chairperson

Sara Moran Bode, MD, FAAP, Chairperson-elect

Marti Baum, MD, FAAP

Katherine Anne Connor, MD, MSPH, FAAP

Emily Frank, MD, FAAP

Erica J. Gibson, MD, FAAP

Marian Larkin, MD, FAAP

Tracie Newman, MD, MPH, FAAP

Yuri Okuizumi-Wu, MD, FAAP

Ryan Padrez, MD, FAAP

Heidi Schumacher, MD, FAAP

Anna Goddard, PhD, MSN – School-Based Health Alliance

Kate King, DNP, RN, MSN – National Association of School Nurses

Kristie Ladegard, MD – American Academy of Child and Adolescent Psychiatry

Carolyn Lullo McCarty, PhD

AAP

American Academy of Pediatrics

ED

emotional disturbance

IDEA

Individuals With Disabilities Education Act

IEP

Individualized Education Program

LEA

local education agency

LGBTQ+

lesbian, gay, bisexual, transgender, and queer or questioning

PBIS

Positive Behavior Interventions and Supports