School Refusal: Concepts and Management Dave Skripka, MD.

School Refusal: Concepts and Management

Dave Skripka, MD

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!

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”

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

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!

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

SR can worsen and be worsened by…

• Academic failure

• Peer problems

• Family dysfunction

• Likelihood of hospitalization

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

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.

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

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

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

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.

Common SR patterns in children with associated psychiatric illness

• Primarily anxiety based

• Primarily depression based

• Mixed anxiety and depression

• Others

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

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

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

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.

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

Clinical Treatment Options

• Cognitive/Behavioral treatments

• Educational/Psychosupportive approaches

• Medication treatment of associated disorders

• Family Therapy

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

School management of SR

I’m no expert in how schools should accomplish anything! Here are some thoughts…

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.

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.

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.

Discussion

• Cases?

• Questions?

• Comments?

• Disagreements?

• Observations?

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