School Refusal

School Refusal or School Reluctance

School refusal is a problem that is stressful for children, families, and school personnel. The failure to attend school is known to have significant short- and long-term effects on children's social, emotional, and educational development. School refusal often is associated with other psychological problems such as anxiety and depression. It is important that underlying problems are identified early and appropriate treatment provided to prevent further difficulties. Assessment and management of school refusal require a collaborative approach that includes the family doctor, parents, psychologist, and school staff.  School refusal children frequently present with physical symptoms, it is therefore important that a physical evaluation by a medical doctor is important to rule out any underlying medical problems. Treatments effective in reducing school refusing behaviours include educational-support therapy, cognitive behaviour therapy, parent-teacher interventions, and pharmacotherapy.

Criteria for Diagnosis of School Refusal

Severe emotional distress about attending school; may include anxiety, temper tantrums, depression, or somatic symptoms.

Parents are aware of absence; child often tries to persuade parents to allow him or her to stay home.

No evidence of significant antisocial behaviours

When not at school, child stays at home when they feel safe and secure

Children willingly to complete schoolwork at home

School refusal is known to affect approximately 1-5% of all school-aged children, with similar rates seen in boys and girls. It is common in all ages, but most frequent in children aged 5,6, 10 and 11 years of age. This often corresponds to the start of a new school.


Onset of School Refusal

Onset of school refusal symptoms is usually gradual. Symptoms may begin after a break from school such as a holiday or illness. For example, some children may have difficulty going back to school after weekends or school holidays. Stressful events at home or school, or with peers may contribute to school refusal behaviours. Some children may leave home in the morning but develop difficulties as they get closer to school, then are unable to proceed (e.g., get out of the car, enter school property). Other children may refuse to make any effort to go to school.

Symptoms may include any of the following: fearfulness, panic symptoms, crying episodes, temper tantrums, threats of self-harm, and somatic symptoms (see below) that present in the morning and improve if the child is allowed to stay home. The longer the child stays out of school, the more difficult it is to return.

Somatic Symptoms in Children with School Refusal include:

Autonomic                                                        Gastrointestinal                                                   Muscular

Dizziness                                                           Abdominal pain                                                      Back pain

Sweating                                                            Nausea                                                                  Joint pain

Headaches                                                         Vomiting                                                                Shakiness/trembling

Diarrhoea                                                           Palpitations                                                            Chest pains


Short-term consequences of school refusal may include poor academic performance, family difficulties, and problems with peer relationships. Long-term consequences may include academic underachievement, employment difficulties, and increased risk for psychiatric illness (e.g., depression, substance abuse).

Associated Psychiatric Disorders

School refusal is not a formal psychiatric diagnosis. However, children with school refusal may suffer from significant emotional distress, especially anxiety and depression.

Children with school refusal most commonly present with anxiety symptoms, whilst adolescents may have symptoms associated with anxiety and mood disorders. School avoidance may serve different functions depending on the individual child.  These may include avoidance of specific fears provoked by the school environment (e.g., test-taking situations, bathrooms, cafeterias, teachers), escape from unpleasant social situations (e.g., problems with classmates or teachers), separation anxiety, or attention-seeking behaviours (e.g., somatic complaints, crying spells) that worsen over time if the child is allowed to stay home.

Assessment

Because children with school refusal present with a wide variety of clinical symptoms, a comprehensive evaluation is essential. School refusal is a complex problem, and clinicians need to obtain sufficient information in order to make an accurate assessment and recommend effective interventions.

The evaluation should include individual interviews with the child and parents. Assessment should include a complete medical history, history of the onset and development of school refusal symptoms, associated stressors, school history, peer relationships, and family functioning. Collaboration with school staff in regards to assessment and treatment is necessary for successful management. School personnel can provide additional information to aid in assessment, including a review of attendance records.

Treatment

The primary treatment goal for children with school refusal is early return to school. Parents should avoid writing excuses for children to stay out of school unless a medical condition makes it necessary for them to stay home. Because children who refuse to go to school often present with physical symptoms, the psychologist will need to provide educational material explaining that the physical symptoms are part of the underlying psychological problem rather than a sign of physical illness. A thorough medical check up by a medical practitioner is strongly suggested to rule out physical illness.

Treatment options include education and consultation, behaviour strategies, family interventions, and possibly pharmacotherapy. Factors that have been proved effective for treatment improvement are parental involvement and exposure to school.

When a child is younger and displays minimal symptoms of fear, anxiety, and depression, working directly with parents and school personnel without direct intervention with the child may be sufficient treatment. If the child's difficulties include prolonged school absence, associated psychological problems, and deficits in social skills, child therapy with parental and school staff involvement is indicated.

BEHAVIOUR INTERVENTIONS

Behaviour approaches for the treatment of school refusal are primarily exposure-based treatments. Studies have shown that exposure to feared objects or situations reduces fear and increases exposure attempts in adults and children.

Behaviour treatments include systematic desensitisation (i.e., graded exposure to the school environment), relaxation training, emotive imagery, contingency management (reinforcement), and social skills training. Cognitive behaviour therapy is a highly structured approach that includes specific instructions for children to help gradually increase their exposure to the school environment. In cognitive behaviour therapy, children are encouraged to confront their fears and are taught how to modify negative thoughts.

Child therapy involves individual sessions that incorporate relaxation training (to help the child when he or she approaches the school grounds or is questioned by peers), cognitive therapy (to reduce anxiety-provoking thoughts and provide coping statements), social skills training (to improve social competence and interactions with peers), and role playing (preparing for peer interactions).

PARENT-TEACHER INTERVENTIONS

Parent-teacher interventions include clinical sessions with parents and consultation with school staff. Parents are given behaviour-management strategies such as escorting the child to school, providing positive reinforcement for school attendance, and decreasing positive reinforcement for staying home (e.g., watching television while home from school). Parents also benefit from consultation to help reduce their own anxiety and understand their child’s anxiety and their role in helping their children make effective changes. School consultation involves specific recommendations to school staff to prepare for the child's return, use of positive reinforcement, and academic, social, and emotional management strategies.

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