School certificates can be a continuous source of embarrassment for some parents and for school authorities may pose a headache when it comes to requesting certification for repeat absenteeism. Of course this translates into a source of preoccupation for the doctor as to whether or not certificates should be issued. Naturally school certificates should be treated as other certificates and the doctor must ascertain the validity of what he or she is writing as this is a legal document. School absenteeism without a valid reason is illegal and parents can be fined. It is not surprising that they often seek the help of the doctor to certify those days in the month that they were absent.

To tackle this issue one should start with the simple certificate for minor illness. As with adult certificates it is often the case that mothers do not send their children to school because they have a mild illness with which they can cope readily without the need to send in for the doctor. Indeed this would involve an extra expense. Yet parents are requested to produce a doctor’s certificate anyway. Should the doctor therefore always examine the child and certify illness even when the mother is able to cope well on her own? Should we always oblige them to pay for a house call? This need not be the case and hopefully the law will soon address this issue through medical council guidelines. We use the same precept as for adult certificates. Doctors, unless they detect abuse, are bound to a fiduciary relationship with their patients. In this case the parents are acting as a proxy to their children, as their legal guardians. Of course this trust can be breached if the doctor does not believe them.

It can happen however that the doctor detects abuse. Some parents may keep the children at home because they (the parents) are ill. This of course is a disservice to children, whose education is important, even though the parents may not give it that much weight. Some parents will not send their children to school, conversely, because it is raining too much. Although parents should be educated by their GPs, one must use one’s discretion, and not sending a child under the age of eight to school for this reason need not require a certificate. It may often be the case that the administration simply wants to justify the absence and does not take the responsibility for fear that it may snowball into further abuse or hassle with the administration.

In my usual morning appearance during the show Bongu, this was discussed and many called in, some being quite emotional. We must understand that we cannot put all children in one basket. Even the basic curriculum for schools may be too much or too little for those at the ends of the bell-curve. It does not mean they are abnormal. There is a range of intelligence, as IQ tests show; one may be very intelligent in one subject or functional area of the brain, and not so much in another. This would mean that a child with reading problems labelled as dyslexia can find difficulty at school until he or she is identified (if at all) and this causes absenteeism. Many children present with symptoms to the doctors because there are problems at home or at work and the doctor sometimes cannot immediately identify the problem and neither wants to scare the patients away by what may seem to some patients to be a hasty conclusion. People may be easily offended if they sense that one is accusing them of not rearing their children well. To be sure, even dealing with schools can sometimes be difficult for teachers and head of schools may be sensitive about issues as well. I had a child who was being bullied at school during the lunch break. Evidently six children were punching him in the stomach. The parent went to speak with the head mistress and she immediately identified the problem and the other children. When the parent complained why they were not being supervised, the head went on the defensive saying that they “always” supervise children!

A mother who called during the show was very upset about her child being so put off school due to an unresolved problem. He does not attend school any more. Evidently the problem was outside school and the child may have been bullied outside the premises. The school authorities told her that what happens outside the school is not their problem. It may not be their responsibility, but one should contest severely that it is not their ‘problem’. Of course it should be their problem if they are interested in the welfare of the child and in the holistic education of children. Children should at least be taught how to cope and learn that society is there to protect them as well. These children lose faith in the system at a young age and this can lead to delinquency and perhaps substance abuse or even personality disorders. Fear of school can be so great that one of the callers said that whenever she drove in front of the school with her teenage son, he would scold her for passing by the school as this upset him. Such cases need to be attended by specialists as well; yet until this happens many may be sceptical with the certificates which are issued by the doctor.

It should be understood that the doctor may not be clear as yet about a diagnosis and therefore writes something like ‘constitutional upset’. This says a lot but is not specific. Of course cooperation with the school can help. Some cases however are rather difficult. I know of a particular situation where the children of a family miss school for no reason at all other than the fact that they do not wish to go. The parents are quite frank about this and in fact do not know how to cope with the children. One understands that these situations are usually found in low socio-economic circumstances or in people who are intelligence-challenged. Certifying such children is also important for the parents can easily be accused of abuse. These parents need help – help which is often not found because we can easily give up on them. Social workers are unfortunately not as numerous as one would wish in schools. It is normal for these parents to walk into a clinic with a letter from school detailing the days in which the child was absent. Naturally the wrong ethical thing to do would be to invent some symptom or illness. The right thing is to use a broad term as above and acknowledge that a problem is usually behind these cases.

The GP would do well however to enter into dialogue with the school authorities as he or she can be deemed to be abusing his professional duties. It would be better however that when GPs do cover these absent days from school, that the authorities of the school do give the doctor the benefit of the doubt. It is not merely a case of issuing a certificate in order to be paid for it, as many may think. If you gather all these cases together you are not exactly going to increase your lot.

It is more a case of empathising with parents and their situation and trying to help them cope and to identify any underlying problem. It is also true however that these families not only do not find the required help, they are sometimes treated badly by those around them. One girl was always blamed for the ticks in class as she was usually unkempt. But in reality tics are found in most and in the best of schools and no one should force children to stay at home – something I have had to deal with in my practice – by pointing fingers at children because of their social circumstances. In any case tics are no reason not to attend school.

Another problem is with those children over or approaching 15 years of age who do not wish to attend school any longer. It is a pity that school counselling services cannot cope with the amount of such teenagers, especially in government schools. We have to accept that many of these are simply passing through a phase and with patience can be helped to achieve their school-leaving certificate. It is also the case however that such children usually have a low performance throughout their schooling age and the situation cannot solely be blamed upon them. It is probable that the home circumstances are not conducive or simply that the teachers have given up on them. It is also a fact however that not all people are the same and whilst you have the very intelligent, you also have the less. These will usually find themselves so upset at school that it affects their behaviour. They simply want to start working. One teenager had always dreamed of becoming a hair-dresser. However she was too young to be admitted into the trade school. She begged to be allowed not to continue her final year and she was very upset. As soon as certificates were issued and the school authorities contacted, her personality changed abruptly. She did follow up on her dream eventually and is working happily in her carrier.

Education is important and it is a right for all. The law stipulates that people should attend school until the obligatory age of 16. We should appreciate that the first such legislation came into effect because parents deprived their children the privilege of attending school. It was an immediate post-war law and Maltese society was still very different. The fine as a deterrent is there because the law assumed parental responsibility. Indeed many parents may still abuse today but the numbers have decreased. Yet such a law should not preclude us from understanding that we cannot put all in the same basket and whereas many children go beyond 16 and progress to colleges and universities, others at the other end of the spectrum find themselves coping with too much. We must acknowledge that stopping a year earlier may be justified. No doctors will (or should) issue certificates without clear discussions with parents and other authorities relevant to the child’s education. But education is not only about maths and English. It is about character. It may well be the case that we focus too much on subjects; subjects which for certain minds do not make much sense. Perhaps given a more conducive environment where they can learn other skills such as communication skills and language labs, or perhaps simply a divergence from the traditional way of teaching, they would not have wanted to flunk school. Certification is certainly justified unless the parent is the perpetrator who still thinks that child-labour is justified.

Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta. He is also former president of the Malta College of

Family Doctors