Authors: Kimberly S. Canter, MA,  & Christopher C. Cushing, PhD 

Thanks in large part to modern medical advances, many children who become critically ill or injured will survive what might once have been a terminal diagnosis. When survival is assured, the developmental task shifts to reintegration into school and peer-networks. Going to school is the primary “job” of childhood and also represents the primary venue for social relationships. Therefore, children with chronic illness or injury encounter a significant set of challenges with school reentry. Similarly, the child’s return to the classroom can require an adjustment by healthy peers and school personnel. Thus, the impact of a child with chronic illness or injury returning to the classroom has a number of implications, and facilitating a smooth and successful reentry requires thought and planning. 

Several theoretical models designed to guide successful school reentry exist in the literature (e.g., Power et al., 2003). Moreover, there have been repeated calls for an examination of school reentry interventions to establish their effectiveness (e.g., Brown, 2002; McCarthy, Williams, & Plumer, 1998; Riley-Lawless, 1989). As a response to these calls, Canter & Roberts (2012) undertook a systematic review of the school reentry literature. Their key findings are presented below (refer to the original article methodological and statistical details). Following the presentation of key findings, we discuss future directions for school reentry program development and reporting in the literature. 

Key Finding #1: Large increases in teacher and peer knowledge accompany school-reentry interventions

Participation in school reentry interventions led to large increases in illness-specific knowledge for teachers and healthy peers, as indicated by large effect sizes (i.e., Cohen’s d = 0.84 – 0.88). This is not entirely surprising, as illness- specific facts are often shared during school reentry interventions, and it may be less challenging to measure knowledge than other modifiable factors, such as stress or fear. When effect sizes for teachers and healthy peers were computed individually, effect sizes rose to 1.13 – 1.15 for teachers, and shrunk to 0.65 – 0.67 for healthy peers. Previous literature (Binnie & Williams, 2002; Myant & Williams, 2005) suggests that children as young as five can be taught specific facts about certain health conditions; as such, it is encouraging that participation in a school reentry program was correlated with large increases in knowledge. 

Key Finding #2: Attitudinal changes occur following school reentry interventions

Participation in school reentry programs led to positive attitudinal change among teachers and healthy peers.  Mean effect sizes ranged from 0.678 – 0.679 for attitudinal changes; when separate effect sizes were computed for teachers and for healthy peers, mean effect sizes rose to 1.05 – 1.09 for teachers and dropped to 0.35 for healthy peers. Thus, there were very large differences between attitudinal change for teachers and attitudinal change for healthy peers, which is a particularly interesting finding. This may indicate that, although children are capable of learning novel information about unfamiliar illness, this new knowledge is not necessarily correlated with decreased fear, worry or increased desirability to interact with the healthy peer.

Key Finding #3: Small changes in global self-worth may follow school reentry programs

A small number of studies (N = 4) examined effects of reentry programs on the child with chronic illness. A separate analysis was conducted on these reports, using increases in self-esteem/ global self-worth as an outcome measure. The mean effect size for this analysis was relatively small (d = 0.24). Although school reentry interventions have benefits, it is important to consider potential unintended side effects for the target child, such as heightened self-consciousness.

Suggested future directions for research

1. There is a clear need for continued implementation and rigorous evaluation of reentry programs. Due to small sample size and inconsistent statistical reporting, it was not possible to explore many important potential moderators of outcome, such as age. As the percentage of children who return to school following illness and injury continues to rise, empirically supported evidence is needed to guide decision making (What works? What does not?) to best serve these populations. 

2. Programs should move beyond pediatric cancer and into other illness groups. Although the inclusion criteria for Canter and Roberts’ (2012) article targeted any type of childhood illness or injury, almost all studies focused on pediatric cancer. Survivors of pediatric cancer are a large and important group deserving of attention, however, other types of physical and mental illness are disruptive to children and deserve attention. Further, effective interventions for one type of illness might be effective for other illness types; theoretical models, such as Power et al.’s (2003) multisystemic model, should be tested with a range of chronic illness groups. 

3. Studies should consider incorporating new outcome measures.  While knowledge and attitudinal change are certainly important, there are many other important variables (e.g., peer relationships following reentry) to consider as potential indicators of successful (or unsuccessful) reentry programs.

Suggested future directions for practice

1. Keep interventions child-specific, and monitor reactions and emotional well-being following an intervention. Although school reentry interventions appear to have generally positive effects, the possibility of negative side effects exist. Practitioners involved in school reentry interventions should monitor responses to help guard against idiopathic iatrogenic effects.   

2. Target attitudes separately from knowledge. Effect sizes for improvements in knowledge were much larger than effects of interventions intended to produce attitudinal change, especially for healthy peers (as compared to adult teachers). Increases in factual information may not be directly connected to attitudes or emotions for children. It may be important to specifically target appropriate social interactions, and allow healthy peers to express and work through concerns they have about the child with chronic illness returning.  

3. The Internet can be a good friend. Perhaps related to the average publication date of most studies included in Canter & Roberts’ (2012) review, only one study utilized the Internet to facilitate an intervention. The Internet is currently used to implement a wide range of health interventions, and a web-based approach to school reentry interventions could be tailored to individual students or teachers with the use of modules, and could allow for “hands-on” exercises, such as problem-solving activities. 

References

Binnie, L. M., & Williams, J. M. (2002). Children’s concepts of illness: An intervention to  improve knowledge. British Journal of Health Care, 7(2), 129 – 147.

Brown, R. T. (2002).  Society of Pediatric Psychology Presidential Address: Toward a social ecology of pediatric psychology. Journal of Pediatric Psychology, 27(2), 191 – 201.

Canter, K.S., & Roberts, M.C. (2012). A systematic and quantitative review of interventions to facilitate school reentry for children with chronic health conditions. Journal of Pediatric Psychology, 37(10), 1065 – 1075.

McCarthy, A. M., Williams, J., & Plumer, C. (1998). Evaluation of a school reentry nursing  intervention for children with cancer. Journal of Pediatric Oncology Nursing, 15(3), 143-152.

Myant, K. A., & Williams, J. M. (2005). Children’s concepts of health and illness:  understanding of contagious illnesses, non-contagious illnesses and injuries. Journal of Health Psychology, 10(6), 805-819.

Power, T. J., DuPaul, G. J., Shapiro, E. S., & Kazak, A. E. (2003). Promoting children’s health: Integrating health, school, family and community systems. New York: Guilford.

Riley-Lawless, K. (1989). School reentry programs. Journal of Pediatric Oncology Nursing, 6(3), 92-93.

Authors Bios

Kimberly Canter is a third year graduate student in the Clinical Child Psychology Program at the University of Kansas, working primarily under the mentorship of Dr. Michael C. Roberts. Her primary research interests are in the field of pediatric psychology, with a particular interest in elements of culture that impact health and illness and the way that multiple systems interact to influence health experiences. Kimberly is currently a member of the Society of Pediatric Psychology’s Student Advisory Board. 

Christopher Cushing earned a PhD in Clinical Child Psychology from the University of Kansas, under the mentorship of Dr. Ric Steele, with an APA-Accredited Internship specializing in Behavioral Medicine at Cincinnati Children's Hospital Medical Center. Dr. Cushing joined the faculty of the Clinical Psychology Program, in the Department of Psychology at Oklahoma State University in 2012 at the rank of Assistant Professor. He is active in the field of pediatric psychology serving on the Editorial Board of the Journal of Pediatric Psychology, the Society of Pediatric Psychology Committee on Science and Practice, and was the Student Representative to the Board of Directors from 2011-2012.