Download Treating Depression in Children and Adolescents

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 childdriven 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…
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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
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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
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
Discussion
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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