School Refusal: Concepts and Management

1. School Refusal: Concepts and Management Dave Skripka, MD

2. We’ll cover… • Definitions and scope of problem • Which psychiatric and family disorders are more commonly seen in kids who refuse school • Making sense of and managing individual cases • Please throw in comments or questions at anytime!

3. Definitions here are slippery! • Some use “school refusal” broadly to mean any habitual failure to attend school for any reason • Others use it very narrowly to refer to child-driven refusal associated with an anxiety disorder • May or may not include “truancy” (skipping school with simple disregard for rules) • Often used interchangeably with “school phobia” or “school avoidance”

4. School Refusal (SR)my definition today • “A pattern of resisting or refusing to attend and stay the day in school, due at least in part to anxiety or mood problems” • Can include kids who don’t attend school, who leave early, or who resist mightily • Can include kids who are anxious or sad for reasons other than an internal disorder, provided the emotions are driving the avoidance of school

5. Truancy • Typically refers to older children or adolescents skipping school as part of a pattern of antisocial behavior or disregard for rules, not associated with anxiety or mood problems. • I don’t intend to focus on clear cases of truancy, although there are kids who show elements of both truancy and SR!

6. How common is School Refusal (SR)? • Roughly 2-5% of school age children, depending on the study and definition • May peak at ages corresponding to school transition times (beginning next level) • Similar rates in girls and boys

7. SR can worsen and be worsened by… • Academic failure • Peer problems • Family dysfunction • Likelihood of hospitalization

8. Why do kids refuse school? • School refusal is a behavior, not an illness or syndrome • Different kids have varying causes • Knowing trends and common “profiles” is helpful, but each child needs individual assessment of a number of variables

9. The obvious! A child will refuse school when there are stronger reasons for refusing than there are for attending. Think of a tug of war occurring every day in every child. For most kids, attending school wins out handily.

10. Toward School/Away from home • Peer connection and approval • Parental approval and sanction of school attendance • School adults approval and sanction • Feelings of competence and mastery in learning • Developmentally normal drive to separate from family • Pain or conflict associated with staying home

11. Toward Home/Away from School • Anxiety about school social setting (phobia, bullying) • Anxiety or frustration about academics • Anxiety about separating from family • Physical or mental pain associated with attending • Parental approval and sanction to stay at home • School adult approval and sanction to stay at home • Lack of energy or motivation (inertia=home) • Family conflict (if need to be at home, protect) • Specific interests, attention or reinforcers at home

12. More on these forces • Most SR kids have a number of forces that add up to produce refusal • The forces which initially cause the behavior may not be the same as those that maintain the behavior (child with medical illness later delays return to school) • Changing just some of the forces may be enough to win the tug of war; conversely kids attending school may begin to refuse with seemingly small changes

13. Assessment of SR • No substitute for a good interview with child and family • The School Refusal Assessment Scale (SRAS) is one assessment instrument with demonstrated reliability and validity. Child, teacher, and parent versions investigate a number of variables. There are associated guides for therapists and families using cognitive-behavioral methods to address problem areas ( • Mental health referral can be invaluable, especially where psychiatric disorders are suspected.

14. Common SR patterns in children with associated psychiatric illness • Primarily anxiety based • Primarily depression based • Mixed anxiety and depression • Others

15. Anxious SR • The best outlook with proper intervention • Almost without exception, have any number of somatic symptoms (head/stomach pain) • Important to distinguish if fear of school (social or specific phobia, bullying) versus fear of leaving home (separation anxiety disorder, home discord, agoraphobia) • Other anxiety disorders can be present as well

16. Depressed SR • Depression or Dysthymia treatable, but in children is often missed by adults • May be more common in kids with learning disabilities and academic problems • Can affect energy and motivation generally, but can also worsen preexisting problems with peers, family, other adults, and academics • Outlook for treatment generally good, though may be less responsive to simple behavioral interventions

17. Mixed Anxious/Depressed SR • Symptoms of anxiety and depression • Much poorer prognosis than either diagnosis alone • Often highest levels of somatization, and most severe behaviors and symptoms

18. Other SR presentations • Socially impaired: Often socially marginalized, autism spectrum, personality disorder. A lack of social drive/success or self-centered view of the world drives child to avoid school. Very difficult to motivate externally. • Oppositional “Externalizers”: Long history of resistance to adult wishes and temper tantrums. Avoids school in the context of defiance or conflict.

19. Family Matters! • Parental attitudes and family functioning are important factors in determining school attendance • Families of SR kids are more likely to rate high degrees of family conflict, enmeshment, and isolation • Single parent families are overrepresented in SR cases • Anxiety SR pattern kids may have less family dysfunction than other SR patterns • Regardless of theoretical contributions to the problem, family dysfunction can make implementing solutions difficult

20. Clinical Treatment Options • Cognitive/Behavioral treatments • Educational/Psychosupportive approaches • Medication treatment of associated disorders • Family Therapy

21. Clinical Treatment, continued • There is no uniform clinical treatment warranted for all SR behavior • “Cognitive Behavioral” strategies refers to a broad category of interventions from a number of professions or parents. The key is APPLYING concepts in the real world in a concrete way. • Medications, particularly SSRI antidepressants, appropriate as part of a comprehensive plan in cases of anxiety/depression

22. School management of SR I’m no expert in how schools should accomplish anything! Here are some thoughts…

23. Physician/School Management of SR • Therapeutic alliances may be difficult with many SR students and families. However, some common goals have to be identified and stressed. • AMBIVALENCE is common, in many families as well as nearly all SR kids. Ask about parental fears or perceptions that the school attendance is painful or harmful for their child. • Be aware of and (privately) acknowledge one’s own attitudes, anger, or frustration toward particular families one might find difficult. • Beware of snap assessments that a case of SR is the sole result of family dysfunction.

24. School Management of SR • Screening for anxiety and depression are key in cases of SR. School medical professionals are in a prime position to notice somatization and to “pick up” these cases. • Treat or refer to mental health treatment if these are suspected. • Schools play a vital role in advocating for participation in mental health treatment even after referral.

25. School Management of SR • Legal sanctions and consequences should NOT be withheld in cases of recurrent absence except in cases where there is a clear medical illness (with excuse). • In cases of anxiety or depression, consequences shouldn’t be withheld except as part of a specific behavioral plan • Early intervention is key, as prognosis quickly worsens with extended absences.

26. Discussion • Cases? • Questions? • Comments? • Disagreements? • Observations?

27. Written Resources • Kearney CA, Albano AM. When Children Refuse School: A Cognitive-Behavioral Therapy Approach--Therapist Guide. San Antonio, TX: Psychological Corporation • Kearney CA, Albano AM. When Children Refuse School: A Cognitive-Behavioral Therapy Approach--Parent Workbook. San Antonio, TX: Psychological Corporation