http://www.sch.edu.au/articles/?type=3&doc=25
Australian Doctor - Medical
Articles
August 1997
School Refusal
Interview with Dr Stephen Koder by Sue Quayle
IntroductionStaff specialist with the Children's Psychiatric Service at the Sydney Children's Hospital, Randwick, Dr Stephen Koder, discussed the issue of school refusal with Sue Quayle.
Story
Although many children say they don't like attending school, most manage to complete their school education without significant absences for ailments that miraculously seem to resolve after parental consent is given to stay at home.
However, there are some children whose desire to stay at home is intensified by an uncontrollable anxiety that overwhelms any motivation to go to school.
In classical cases of school refusal, these children may complain of physical illness but their health is not affected to the extent that school non-attendance is indicated.
While there are no formally accepted criteria for school refusal, parental knowledge and consent - however unwilling - are important factors in the diagnosis. Parents say they want their child to attend school, but the child's level of emotional stress and/or physical symptoms at the prospect of going to school are so great that the parents often relent and allow the child to stay home.
But typically, if the child does go to school, he or she settles down and participates in normal activities.
Occasionally, parents may not be aware an older child is staying at home. The child may go through the motions of preparing and leaving for school but return home when parents have left for work. The child may also intercept letters from the school, delaying the opportunity for help and further entrenching the behaviour.
A basic distinction is betwen school refusal and truancy. In general, truants do not remain at home but join their friends in pleasurable (and sometimes antisocial) activities instead of attending school.
Parents are usually unaware of their child's activites and the child is unlikely to give a truthful account to parents, doctors or other authority figures.
School attendance is monitored by attendance rolls which are computerised in some schools. In NSW, more than three days' unexplained absence is investigated by a letter and/or telephone call to the student's parents. Prolonged absences without a satisfactory reason are brought to the attention of the school's home liaison officer.
The prevalence of school refusal is thought to be about 2-3% of the school population. About 10% of children are absent at any time with a good explanation lacking in about one-third of these.
School refusal is most common around the start of kindergarten and again at the start of high school. Other vulnerable times are after weekends or holidays and after a break in routine such as starting at a new school or moving house.
Most cases of school refusal are primarily related to separation anxiety. Some degree of separation anxiety is a normal part of early childhood development and is particularly common in day-care settings or at the start of preschool. However, separation anxiety disorder (SAD) renders a person psychologically and socially disabled by fears of harm befalling loved ones or self during periods of separation from important attachment figures.
Such separations include attending school, excursions or parties and even going to sleep at night. Associated features include:
* Nightmares with themes of separation and loss.
* Physical symptoms of distress - loss of appetite, nausea, vomiting, abdominal pains and diarrhoea.
* Transient symptoms of depression and anxiety which remit when the threat of separation subsides.
* Tantrums in younger children.
* Panic attacks in adolescents.
Although there may be an identifiable primary problem causing the child's behaviour, there are often additional factors within the child, the school and the home which interact and compound the situation. These factors (see Box 1) may co-exist with school refusal and require separate or additional consideration.
It is well recognised that SAD associated with school refusal in adolescents commonly co-exists with other psychiatric disorders. School refusal in adolescents is generally more complex and difficult to treat than in younger children.
Boys and girls are equally affected by SAD. There is no social class bias and there is a normal distribution in terms of intelligence and educational achievement. Children with no siblings are not more likely to developing SAD and school refusal than those with siblings. However, there is some evidence that the youngest child may be more prone to develop the condition that older siblings.
The most common pattern of school refusal occurs in a child who is predisposed to worrying and who could be described as shy or sensitive. The child often has difficulty in establishing and maintaining peer relationships and tends to be overreliant on parents for care and protection. One or both parents tend to be excessively nurturing of the child.
The parental relationship is commonly discordant and the school refusing child becomes the focus of their concern to the exclusion of other family difficulties or marital problems.
GPs may be become aware of a possible case of school refusal through requests from parents for medical certificates; consultations for the child's repeated somatic complaints; or a request from parents about how to get a reluctant child to attend school.
Early presentations of school refusal can often be successfully managed by co-operation between the GP, parents and school. However, if there is significant comorbidity or suspicion of more serious mental disorders in the child or family, it is appropriate to refer the case to a child and family mental health team, child psychologist or child psychiatrist.
Because school refusal has serious implications for the child's social development, referral is also indicated if there is no significant success within about two weeks. Cases that have persisted for weeks before presentation should also be referred as the situation is entrenched and may require more time than GPs are able to offer.
A history should be obtained from the parents, child and school eliciting:
* The number of days missed.
* When refusal is most likely to occur.
* What precipitates refusal.
* What relieves the problem and makes it easier for the child to attend.
* The cause and nature of school refusal.
* Any associated problems in the child's world within him- or herself, at home or at school.
The presence of other disturbances listed in the differential diagnoses (Box 1) should be systematically excluded through history taking and mental state examination.
Physical examination and any necessary investigations should be done to allay concerns about the child having a major physical illness. But the family should be told from the outset that the physical symptoms are likely to be due to emotional upset rather than being the cause of the child's inability to attend school.
Asking the parents to keep a detailed diary of family events, the nature of the child's symptoms and time off school can assist diagnosis and help to show the child and parents how external events may correlate with episodes of school refusal.
The diary may also help to avert a lengthy process of unnecessary investigations, specialist consultations and increased anxiety. This scenario sometimes continues until the child is admitted to hospital for further investigations which ultimately demonstrate that the problem is not physical in origin.
Once the diagnosis of school refusal with SAD is made, the disorder itself and the nature of its behaviourial, emotional and physical symptoms must be explained to the parents and child. Significant progress is unlikely unless the family understands that the child's symptoms are a manifestation of anxiety.
A separate consultation with the parents (with the knowledge and consent of older children and adolescents) is also indicated to discuss how they can deal with the problem. It will also give parents the opportunity to discuss other significant family or relationship problems which are not being addressed, often because they are more preoccupied with the child's school refusal.
The consultation should also be used to confirm that the parents:
* Agree with the GP's diagnosis.
* Are satisfied the necessary investigations have been done.
* Are committed to helping the child return to school according to an agreed time schedule.
* Agree that the child will need and receive the support of the family and school to make that return possible.
Frequent contact is required with the family until the child has been attending school full time for at least six weeks.
Although dealing with the child's behaviour is an important component of managing school refusal, the child needs to be sure that his or her worries and difficulties are taken seriously and that the family, GP and school can be relied upon for help to rectify them. With this support, the child is more likely to accept that there is no need to stop going to school to deal with the problems. Some children may also find relaxation therapy a helpful adjunct to overcome the anxiety associated with going to school.
To assist the child's return to school in the initial stages, parents may need to rearrange their schedule so both are present during school mornings. Often, the mornings have previously been left to one parent, usually the mother. The chances of successfully returning the child to school will partly depend on the parents' united determination, consistency and mutual support in helping the child to be stronger than the anxiety.
Initially, firm encouragement will be needed to get the child to school - perhaps to the extent of taking the child in a partial state of dress to show how serious the parents are about the importance of not giving in to anxiety.
Having the father or a father substitute accompanying the child to school in the initial stages may also useful as he has the potential physical strength to contain the child should the distress reach such a proportion that the child loses control.
If circumstances prevent the parents from taking charge of this process or they feel ill-equipped to handle it, a home-school liaison officer may be able to help.
Many parents find it difficult to counter assertions by their child that he or she is ill. However, the diary can be used to show the child how complaints of illness are related to worries about going to school. For example, there may be no complaints of stomach ache on weekends or holidays, except on the eve of returning to school.
Nevertheless, parents should have a logical management plan for complaints of illness. For example, if the child does not have new symptoms that may indicate a significant illness, parents should feel confident in persevering with getting the child to school.
In some cases, the child may respond to a graded reward system for co-operative behaviour and increasing periods of continued school attendance. Minor daily rewards in the early stages may also have positive results. However, the child needs to understand that once he or she returns to routine school attendance, the rewards will be phased out or applied to some other problem area.
Severe cases of anxiety and depression need to be treated with psychotherapy before a graded reintroduction to school can be planned. Inpatient treatment in a child psychiatry unit which incorporates family therapy may be indicated in these cases with the child attending the onsite school in the hospital grounds.
There is no indication for drug therapy in most cases of school refusal. If a GP suspects a child has an associated psychiatric disorder, referral for assessment by a child psychiatrist is appropriate.
GPs are well placed for managing school refusal, particularly if they have a good relationship with the family and the condition is addressed early. Parents are also more likely to accept the GP's plan to get the child back to school if they are satisfied he or she understands the problem and major medical disorders have been excluded. A calm and confident approach to the situation is also crucial.
Even if GPs choose to refer the family for specialist management, they nevertheless remain important sources of ongoing support for the family, particularly as many children experience exacerbations at vulnerable times such as towards the end of holiday periods.
Differential diagnoses
In the child:
Conduct disorder (including truancy).
Adjustment disorder (reaction to life stressors)
Depression.
Generalised anxiety disorder.
Obsessive compulsive disorder.
Chronic fatigue syndrome.
Substance abuse disorders.
Schizophrenia.
In the school:
Undetected learning disorders and/or lack of remedial education input.
Poor peer relationships/social skills deficits.
Teasing and bullying.
Poor child-teacher relationship.
In the family:
Neglect.
Child abuse.
Child used as additional or substitute carer for younger children or an unwell parent.
Immigrant family using the child as a linguistic aid and cultural intermediary.
Parental substance abuse disorder.
Parental psychiatric disorder (eg depression, agoraphobia, delusional disorder).
Externalising the 'wobblies'
Children have different degrees of insight and motivation in terms of how much they want to conquer their school refusing behaviour.
Indeed, they should be told that the effects of anxiety on their minds and bodies are likely to worsen in the initial stages of returning to school. Knowing why they feel worse will help to quell fears of an intensity of symptoms.
GPs may find the book, 'The School Wobblies'* a useful resource for older children and adolescents. Written and illustrated by two child psychiatrists, the book explains how the nature of school refusal is rooted in anxiety.
It also externalises the problem which is an important therapeutic strategy to employ early in management. Before help is obtained, parents often see the child as difficult, obstructive, unreasonable and uncontrollable. In fact, the child is very distressed in his or her inability to overcome the anxiety preventing participation in normal activities.
Externalising the symptom (that is, naming the problem as anxiety rather than the child or the behaviour), helps the child and family to unite against the problem and devise ways to stop the 'wobblies' monopolising the child's daily routine.
* 'The School Wobblies' by Dr Chris Wever and Dr Neil Phillips. Shrink-Rap Press. PO Box 187, Concord West. $15.
Reprinted with permission from Australian Doctor
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