Why I Rarely Write Letters Excusing Children from PE — and What I Recommend Instead

Every year around this time, my inbox fills with a version of the same request: Can you write a letter so my child doesn't have to take PE?

I understand why parents ask. The request almost always comes from a place of love. A child with autism, anxiety, or depression is dreading gym class, and a parent wants to spare them that distress. That instinct is human and it is protective.

But it is worth explaining why I approach these requests carefully — and why the answer is usually not a blanket excusal.

What the Research Actually Shows About Exercise and Children's Mental Health

The evidence here is not subtle.

Rodriguez-Ayllon et al. (2023) examined the neurobiological, psychosocial, and behavioral mechanisms linking physical activity to psychiatric symptoms in youth, finding significant associations between physical activity and reduced internalizing symptoms including anxiety and depression across adolescent populations (Rodriguez-Ayllon et al., 2023).

For autistic children specifically, a 2024 systematic review and meta-analysis published in JAMA Pediatrics examined physical activity and mental health across children and adolescents with neurodevelopmental disorders. Liu et al. (2024) found significant benefits for overall mental health, cognitive function, psychological well-being, and both internalizing and externalizing problems — and notably, the type of neurodevelopmental diagnosis did not change whether physical activity helped (Liu et al., 2024).

A 2026 network meta-analysis published in BMC Public Health compared the efficacy of various physical activity interventions specifically in individuals with autism spectrum disorder, finding that physical activity is a promising non-pharmacological intervention — though the most effective intervention type and dose continues to be studied (Liu et al., 2026).

For social communication and interaction specifically, Zhao and Chen (2018) found that a structured physical activity program produced meaningful improvements in social interaction and communication for children with autism — exactly the domains that make PE feel threatening for many autistic students in the first place (Zhao & Chen, 2018).

A 2025 review in Brain Research on anxiety treatment in the autistic population highlighted how common anxiety disorders are in autistic individuals and underscored the ongoing need for both pharmacological and behavioral interventions tailored to this population (Dulski et al., 2025).

The American Academy of Pediatrics has also documented that children and adolescents with disabilities — including autistic children, who carry elevated risk of overweight and obesity — benefit from consistent participation in sports, recreation, and physical activity, with gains in academic engagement, social responsiveness, and overall well-being (Carbone et al., 2021).

In other words: the activity a child is being excused from is, for many children, one of the more effective non-pharmacological interventions available for exactly the symptoms driving the request.

Why Blanket Avoidance Tends to Backfire

There is a second issue, and it is the one I find harder to explain in a short phone call.

Anxiety operates on a predictable loop. A situation feels threatening. Avoiding it produces immediate relief. That relief is powerfully reinforcing. And the next time the situation appears, it feels even bigger — because the child never had the chance to learn they could handle it.

This is why graduated exposure is the cornerstone of evidence-based anxiety treatment in children. The AACAP Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders is explicit that school-based plans, including 504 plans, are an appropriate vehicle for building graduated practice opportunities, particularly for social anxiety (Walter et al., 2020). Cognitive behavioral therapy for anxious youth works substantially by reducing avoidance behaviors — not by engineering the world so avoidance is never necessary.

Research on school-based accommodations for anxious youth has found that the most effective school plans combine support with gradual exposure — not simply removal of the feared situation from the child's schedule (Conroy et al., 2022; Phillips et al., 2022).

When a 504 plan permanently removes a child from a feared activity, it can inadvertently convert a temporary accommodation into a permanent limitation. The plan becomes a mechanism for avoidance rather than a scaffold for participation.

And PE is rarely the last hard thing. There will be group projects, presentations, job interviews, crowded workplaces, and unfamiliar physical environments. A child who has practiced tolerating discomfort with support enters adulthood with a skill. A child who has been routed around every difficulty enters adulthood with a shorter list of things they believe they can do.

Modification Is Almost Always Better Than Exemption

This is the key distinction, and it is where most of these conversations should land.

The question is rarely "PE or no PE." It is: what specifically is hard, and what change would make participation possible?

The AAP clinical report on promoting participation of children and adolescents with disabilities in sports and physical activity makes clear that the goal is identifying and removing barriers to participation — not removing the child from the activity (Carbone et al., 2021). Common, well-supported modifications include:

• Adapted physical education with modified activities, equipment, or instruction

• A smaller class or alternate section rather than a large, loud gym period

• Individual or partner activities in place of competitive team sports

• Sensory accommodations — noise reduction, advance notice of the week's activities, predictable routines

• Private changing arrangements or a locker room exemption specifically, while still participating in the activity itself

• A regulated pass to step out and self-regulate when overwhelmed, with a clear plan to return

• Modified grading that credits effort and participation rather than athletic performance

• A graduated participation timeline — starting with observation, moving to peripheral participation, then full engagement — with clinical support at each stage

Each of these preserves the therapeutic benefit of movement while removing the specific barrier. That is what a good accommodation does.

Why I Need to Evaluate a Child First

I am sometimes asked to write accommodation letters for children I have never met — occasionally on the basis of records that are several years old. I decline, and here is why.

A letter from a clinician carries weight precisely because it reflects an independent professional judgment. If I write one without an assessment, I am not offering judgment — I am transcribing a request. That helps no one, and it places my license and my integrity behind a claim I cannot clinically defend.

An evaluation also frequently changes the recommendation. A child whose difficulty is primarily sensory needs something entirely different from a child with social-performance anxiety, who needs something different again from a child with a motor coordination disorder. Sorting that out is the entire value of the clinical visit. Without it, the letter is a guess dressed up as a recommendation.

One More Thing Parents Should Know: I Don't Make the Final Call

Clinicians recommend. Schools decide.

A nurse practitioner's letter is one input into a 504 team's deliberation. The school district determines what accommodations are appropriate, feasible, and consistent with the law. I can document a diagnosis, describe functional impact, and recommend specific modifications. I cannot order a school to implement them — and any clinician who promises otherwise is overstating their role.

That is actually a reasonable system. The 504 team includes people who know the school environment, the curriculum, and what is operationally available — knowledge I do not have from a telehealth visit. My job is to give them the clearest possible clinical picture. Their job is to translate that into a workable plan.

Questions I Ask Parents to Consider Before Requesting a Full Exemption

Before requesting removal from any required activity, it is worth sitting with these:

• What specifically is difficult — the activity itself, the setting, the social exposure, the sensory load, or the locker room?

• Is there a modification that removes that specific barrier while keeping the child in the activity?

• What skill would my child gain by participating with support that they would not gain by opting out?

• Is this plan designed to help them do hard things — or to help them not have to?

Sometimes a child genuinely cannot safely participate, and a medical exemption is the right call. Those situations exist and I write those letters. But they are the exception, and they are identifiable only after an actual evaluation.

The goal of a 504 plan is access, not exemption. The most clinically useful thing I can do is help build a plan that lets a child participate — not one that quietly narrows their world.

The SHIELD Psychiatry Approach

At SHIELD Psychiatry, we don't write accommodation letters on request. We conduct comprehensive psychiatric evaluations that look at the whole child — their diagnostic picture, their developmental history, their school environment, their family context, and their own experience of what is hard and why.

From that evaluation, we make specific, clinically grounded school recommendations — designed not just to make this semester more manageable, but to set the child up for long-term success. Our school and IEP/504 consultation services help translate clinical findings into workable plans.

We offer Parent Coaching sessions specifically designed to help families understand graduated exposure and support their child through anxiety without inadvertently reinforcing avoidance. We work collaboratively with therapists and schools across Florida to ensure clinical recommendations translate into real, workable accommodations.

For families navigating autism and co-occurring anxiety, or teen mental health more broadly, we encourage you to explore our resources — and to reach out when you're ready for a real evaluation.

All of this is available via telehealth, serving patients ages 5–25 across Florida — from Tampa Bay and Wesley Chapel to Naples, Winter Park, and Weston.

A Word From My Heart

Proverbs 22:6 says, "Train up a child in the way he should go; even when he is old he will not depart from it."

Training is not protecting. Training is preparing — the intentional, loving, sometimes uncomfortable process of building capacity so that when hard things come, and they will come, our children have what they need to meet them.

That is what I believe good psychiatric care looks like. Not removing obstacles. Building the child who can navigate them.

If your teenager is struggling, I am here. And I want to help you do more than survive this semester.

Schedule an Evaluation

Visit shieldpsychiatry.org or book a new patient pre-screen online.

Call or text: (813) 592-7228
Monday–Saturday, 8:00 AM–8:00 PM
Serving patients ages 5–25 via telehealth across Florida.

SHIELD Psychiatry PLLC — Protecting Young Minds. Empowering Futures.™

Related Reading and Resources

• Depression in Autistic Teenagers: What It Really Looks Like and Why It Is So Often Missed

• Teen Mental Health Warning Signs Every Tampa Bay Parent Should Know

• How to Get an Autism Diagnosis in Florida: A Parent's Guide

• Anxiety treatment for kids and teens in Florida

• Autism support at SHIELD Psychiatry

References

Carbone, P. S., Smith, P. J., Lewis, C., & LeBlanc, C. (2021). Promoting the participation of children and adolescents with disabilities in sports, recreation, and physical activity. Pediatrics, 148(6), e2021054664. https://doi.org/10.1542/peds.2021-054664

Conroy, K., Greif Green, J., Phillips, K., Poznanski, B., Coxe, S., Kendall, P. C., & Comer, J. S. (2022). School-based accommodations and supports for anxious youth: Benchmarking reported practices against expert perspectives. Journal of Clinical Child & Adolescent Psychology, 51(4), 419–427. https://doi.org/10.1080/15374416.2020.1723601

Dulski, T., Tolak, S., & Zmorzyńska, J. (2025). Challenges and hopes for treatment of anxiety disorder in the autistic population. Brain Research, 1860, 149675. https://doi.org/10.1016/j.brainres.2025.149675

Liu, C., Liang, X., & Sit, C. H. P. (2024). Physical activity and mental health in children and adolescents with neurodevelopmental disorders: A systematic review and meta-analysis. JAMA Pediatrics, 178(3), 247–257. https://doi.org/10.1001/jamapediatrics.2023.6251

Liu, J., Sun, J., Li, H., & Zhao, J. (2026). Comparative efficacy of various physical activity interventions on individuals with autism spectrum disorder: A systematic review and network meta-analysis. BMC Public Health, 26(1), 2377. https://doi.org/10.1186/s12889-026-27965-2

Phillips, K. E., Conroy, K., Pinney, E. L., Comer, J. S., & Kendall, P. C. (2022). School-based supports and accommodations among anxious youth in treatment. Journal of Anxiety Disorders, 90, 102603. https://doi.org/10.1016/j.janxdis.2022.102603

Rodriguez-Ayllon, M., Neumann, A., Hofman, A., Voortman, T., Lubans, D. R., Yang-Huang, J., Jansen, P. W., Raat, H., et al. (2023). Neurobiological, psychosocial, and behavioral mechanisms mediating associations between physical activity and psychiatric symptoms in youth in the Netherlands. JAMA Psychiatry, 80(5), 451–458. https://doi.org/10.1001/jamapsychiatry.2023.0294

Walter, H. J., Bukstein, O. G., Abright, A. R., Keable, H., Ramtekkar, U., Ripperger-Suhler, J., & Rockhill, C. (2020). Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 59(10), 1107–1124. https://doi.org/10.1016/j.jaac.2020.05.005

Zhao, M., & Chen, S. (2018). The effects of structured physical activity program on social interaction and communication for children with autism. BioMed Research International, 2018, Article 1825046. https://doi.org/10.1155/2018/1825046

This article is for educational purposes and is not a substitute for an individualized evaluation or medical advice.