The movie Ferris Bueller’s Day Off—an iconic comedy that taught a generation how to steal someone else’s lunch reservation and commandeer a parade float—was one of the most formative films of my high-school years. As a teenager, I found the premise hilarious—but now that I have four school-age kids of my own, watching a young Matthew Broderick lick his palms to fake clammy skin mostly makes me wonder whether I’m ever being played like that.
If I am, it’s particularly embarrassing because I’m a pediatrician. How do I know when my children are actually ill versus when they want to miss school? Honestly, I can’t always tell, but over the years I’ve come up with a number of tactics for reaching a fair verdict. Borrow my strategies to get to the bottom of your own kids’ pleas to hole up at home.
1. "My head hurts."
Fact-Check It: Kids may have a hard time describing the severity of their pain, so doctors often rely on a tool called the Wong-Baker FACES Pain Rating Scale—a series of pictures that range from smiling to crying—to gauge their distress. The abridged version: If your child is sobbing, closing her eyes, or unwilling to play or joke around, she’s in bad shape. In fact, if her headache persists for more than an hour or two and doesn’t respond to acetaminophen or ibuprofen, she not only needs to miss school but also needs to see a doctor. Severe headaches that recur (particularly those along with changes in vision, nausea, or an aversion to light or noise) could be migraines and warrant a diagnosis and pain relief. Take your child to the emergency department if she ever has trouble moving her neck; difficulty talking, walking, thinking, or using her hand; or if the headache awakens her from sleep or causes vomiting.
For most kids, however, headaches are mild and will go away on their own within an hour or two—making regular school drop-off (or at the very least, a late arrival) a distinct possibility. If your child doesn’t seem to be in that much pain—say, she’s eating and comfortably watching TV—but insists her head still hurts, tell her you’re making a pediatrician appointment. Skipping school is no fun if it just means a trip to the doctor’s office. Your comment could spark a miraculous recovery.
2. "My tummy doesn’t feel good."
Fact-Check It: A stomach bug that comes with nausea, vomiting, and/or diarrhea should always keep your child out of school, and in most situations you’ll be able to verify the illness with, shall we say, your own eyewitness account.
But what if your child just holds his belly and says it hurts? Look for secondary symptoms: Abdominal pain stimulates the vagus nerve (a direct connection between the bowels and the brain), and that slows the heart, makes skin pale and clammy, increases saliva production, and constricts the pupils. Another easy tell: whether your child eats breakfast. Appetite is generally the first thing to go with a stomach bug, so if your kid digs right into his favorite pancakes, he’s probably fine.
That said, never ignore chronic or repeated complaints of abdominal pain. Even if your kid can make it through the school day, he could have anything from constipation to ref lux to anxiety. Instead of toughing it out in the classroom, he may need to talk to a doctor.
3. "I think I’m burning up!"
Fact-Check It: Fever is your child’s guaranteed “Get Out of School Free” card, though the exact temperature that warrants staying home is somewhat up for debate. The number varies from school to school; some say 101°F, others say 100°F. Most schools insist that students remain fever-free for 24 hours before returning. They’re probably right to use this criterion: It’s objective and measurable, and kids with a fever rarely feel well enough to learn effectively.
It’s not easy to fake a fever, but it is possible. The first step to calling your kid’s bluff is getting an accurate temperature reading. Warm food and beverages can heat the mouth for up to 15 minutes, so if you suspect deception, make sure your child didn’t just drink or eat. Physical activity can also raise core temperature, so if your child seems winded, have her lie down for 20 minutes first. Also, don’t rely on your hand to gauge her temperature; studies suggest that parents aren’t bad at detecting fever this way, but they’re not quite good enough to drive medical decision-making. Confirm it with a thermometer (an oral one is easiest to use), and use 100°F degrees as your cutoff.
4. "Cough, cough. Hack, hack."
Fact-Check It: Upper-respiratory infections are one of the top causes of school absences, and they almost always come with a cough. That’s because a cold increases mucus production in the airways, and coughing helps clear it. In fact, the cough reflex is so strong that no medicine has ever managed to suppress it completely. Anyone can cough at will, but not all coughs sound the same. Real coughs often have a “productive” sound—that is, you can hear excess mucus leaving the airways. They are also extremely forceful (up to 50 miles per hour!) and occur more frequently than fake coughs. After all, when you cough on purpose, you have to remember to keep coughing, but when you’re sick, you can’t help yourself. These are differences you should be able to pick up on if you listen carefully enough.
Of course, fake or not, a kid with a cough can usually go to school provided she doesn’t have other symptoms like a fever or a headache. (If you notice wheezing or shortness of breath, take your child to the doctor’s office or the emergency department.)
5. "It hurts to swallow."
Fact-Check It: About 70 to 80 percent of sore throats arise from viral infections that shouldn’t keep kids home (provided they’re otherwise feeling fine). The remainder stem from bacterial infections, most often strep, which requires 24 hours of antibiotics before your child will be ready to return to the classroom.
So how do you know if your child has strep? If your child doesn’t have a fever but does have a cough and a hoarse voice, a virus is a more likely culprit than strep. Ultimately, though, the diagnosis must always be confirmed with a throat swab. That’s right, even an experienced clinician can’t tell if your child has it just by taking a history and saying “open wide” (so forget what you’ve heard about bright-red throats, swollen tonsils, and icky white spots). Your best bet: Swing by your pediatrician’s office to get a rapid strep test on the way to school. The swab identifies up to 98 percent of cases and can take just five minutes to get results. Once you get your answer, you can feel confident in your decision either to send your child off to class or to head back home to hunker down on the couch.
6. "I just feel yucky."
Fact-Check It: Malaise is the term doctors use to describe plain old not feeling well, which can range from wanting to stay in bed to being on the verge of fainting. My own kids have confessed to using this excuse to weasel out of school, since they know malaise can be a sign of anything—the beginning of a cold, mononucleosis, or a more serious illness. In short, it’s hard for a parent to know how to respond to it.
In my house, I now insist that in order to miss school, my children must have at least one other observable symptom. My usual choice of words: “Do you have a fever? Are you vomiting? No? Then you’re going to school.” If they just feel lousy, they can do that just as easily in a classroom as they can at home. (Also check out this quiz: Is Your Kid Too Sick for School?) The tougher question is what to do if the symptom doesn’t go away.
A child who often complains of malaise deserves a medical evaluation. The list of illnesses that cause malaise is long, and a thorough medical history and physical exam can help you narrow it down. As a pediatrician, I usually look for clues in my
When Faking Becomes a Pattern
Although few children love every single day of school, the vast majority accept that attending is a nonnegotiable part of life. So if your child is constantly trying to cough or sneeze his way off the school bus, it’s important to find out why. Kids who are being bullied often fake illnesses because they’re afraid of reporting—and in turn, angering—their tormentor. A child’s symptoms could also correlate with a particularly stressful class, a test, locker-room intimidation, or even the state of your health or your partner’s.
Determining the cause of apparently fake symptoms often requires the help of a doctor or a mental-health professional. Pediatricians call it “malingering” when a child fakes symptoms knowingly for some sort of gain and “factitious disorder” when the symptoms are fake but the child cannot say why. In other conditions such as somatization disorder, conversion disorder, and pain syndromes, the symptoms seem real to the child even though there is no detectable underlying illness.
