- Copyright © 2013 by the American Academy of Pediatrics

Schools should replace “zero-tolerance” policies that call for suspending or expelling students who exhibit problematic behavior with an approach that focuses on teaching and recognizing desired behavior, according to the revised AAP policy statement, Out-of-School Suspension and Expulsion (Pediatrics. 2013:131:e1000-e1007; http://pediatrics.aappublications.org/cgi/doi/10.1542/peds.2012-3932).
The revised policy is based on the premise that out-of-school suspension and expulsion are extreme degrees of discipline that can have long-term adverse consequences for the child, his or her family, and often the school district and community. For example, students who miss school due to a suspension may fall behind, especially if the district is not obligated to provide educational services. In addition, research shows that students who are suspended and expelled are up to 10 times more likely to drop out of high school than are those who are not, leading to fewer educational and employment opportunities.

Therefore, such discipline should be reserved only for the most egregious offenses and recalcitrant offenders, according to the policy.
Taking a positive approach
Zero-tolerance policies were developed following passage of the Gun-Free Schools Act of 1994 and similar legislation that was intended to prevent students from bringing firearms to schools. Such policies, however, quickly were applied to lesser and nonviolent infractions such as drug and alcohol violations, verbal disrespect to teachers, and truancy.
Studies have demonstrated that zero-tolerance policies are unduly harsh, inflexible and often applied inequitably, especially with regard to race and ethnicity. Moreover, they do not improve a school’s social and learning environment.
Instead of zero-tolerance policies, schools should adopt an approach called positive behavior support in which good behaviors are taught, consistently expected, and positively recognized and acknowledged. Under this behavior-management philosophy, the goal is to recognize good as well as bad behavior and to reward the good behavior. Studies have shown that students respond well when they know that they will be recognized for doing the right thing, and for making their schools safer and friendlier places to learn and live.
Such behavior support is based on a tiered system of 1) creating a positive environment overall; 2) identifying “at-risk” children who may need extra help getting their behavior on track, 3) and providing focused intervention for children who continue to have difficulty conforming to expected behavior standards. In these instances, disciplinary and restitution measures other than out-of-school suspension and expulsion are employed whenever possible.
The schoolwide positive behavior support model can be effective in reducing not only out-of-school suspension and expulsion but also bullying because it reinforces and recognizes positive behavior.
Pediatrician’s role
The revised policy statement continues to emphasize the role of the pediatrician as an authority on and advocate for children’s health (see recommendations). It stresses the pediatrician’s role as a member of a team of professionals — teachers, psychologists, counselors, school nurses and social workers, among others — who all have different areas of expertise but are united in wanting the best educational and social outcomes for every child with whom they work.
Ultimately, the revised policy recognizes that the best way to ensure that all children feel safe and welcomed in school is to fix the system to give every child the best chance, and to ally with other professionals in the school district and community to ensure that their expertise and dedication are utilized as effectively as possible.

Dr. Lamont
Recommendations
Pediatricians can play a variety of roles within the community and school district with respect to discipline issues, according to the policy statement, Out-of-School Suspension and Expulsion:
The pediatrician should screen for and recognize early childhood and preschool behavior problems. The pediatrician should refer high-risk children to age-appropriate community resources, such as Birth to 3 and Head Start.
The pediatrician should communicate with the school nurse and/or counselor to verify how the school-aged student who is exhibiting problem behavior compares with peer behaviors in school. The pediatrician should work with the school, the child and family, and mental health care professionals to facilitate and coordinate care of the student as early as possible when behaviors fail to respond to standard interventions.
The pediatrician should be familiar with safeguards provided by the Individuals with Disabilities Education Act for patients who have an individualized education plan (IEP) or Section 504 plan. The pediatrician may act as an adviser, 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.
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 focus on prevention strategies and positive behavior change programs.
The pediatrician can serve as a school district physician, a paid consultant, a medical adviser or school board member to help develop school district policy regarding student behavior and discipline. Pediatricians should be compensated appropriately for any professional services provided for a specific student whether through diagnosis, treatment, counseling or advocacy.
Resource
The U.S. Department of Education, through its Office of Special Education Programs, established a technical assistance center on positive behavior interventions and supports at www.pbis.org.
Footnotes
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Dr. Lamont, lead author of the policy statement, is a former member of the AAP Council on School Health Executive Committee.