• Adolescent Health
• Child Abuse
• Paediatric Practice
• School Health

Hawkrigg and Payne provide a very helpful medically focused approach to the management of prolonged school non-attendance in adolescence.1 Their emphasis on a multiagency systemic approach and on rehabilitation is particularly welcome. I would suggest that consideration of potential child protection issues is equally important in these cases. There are at least four situations in which this may arise, all of which I have come across in my own practice:

1. The young person who is experiencing maltreatment in the home and the non-attendance is a reaction to this. This may arise particularly with ongoing emotional or sexual abuse, but also in situations of physical abuse or domestic violence in the home. In these situations, the young person may develop physical or emotional symptoms which may keep them from attending school, may develop mental health problems as a consequence of the maltreatment, or may deliberately avoid school because of the emotional distress they are experiencing, or to avoid the maltreatment being discovered.

2. The young person who is kept from attending school by the parents or carers. This may arise when the young person is acting as a young carer, for example for a parent with physical or mental health needs, or addiction; as part of a wider pattern of neglect of the young person's needs; or as a more deliberate denial by the parent of the young person's educational needs (a form of deprivational abuse).

3. Where the young person is experiencing or reporting symptoms as a consequence of disordered family beliefs about health and illness. This may occur along a spectrum from over-reaction to or exaggeration of minor illness, through to more extreme forms of fabricated or induced illness. In these situations, the primary responsibility for the illness behaviour lies with the parent or carer, but often these beliefs and behaviour patterns are picked up by the young person.

4. Where the young person is a victim of sexual exploitation.

In all of these situations, the maltreatment underlying or contributing to the young person's non-attendance may not be immediately apparent. The management in such situations should be as recommended by Hawkrigg and Payne, but unless these possibilities are proactively considered, it is unlikely that the maltreatment will be identified, the young person is likely to continue to suffer harm, and it is unlikely that the non-attendance will be resolved. I would suggest that in each situation of school non-attendance the question of whether the young person may be experiencing maltreatment is specifically asked in the multiagency forum, and where possible maltreatment is identified, that this is thoroughly investigated by the relevant authorities.